Provider Demographics
NPI:1346584489
Name:RAY, SHAUTLEY MARIEA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SHAUTLEY
Middle Name:MARIEA
Last Name:RAY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:SHAUTLEY
Other - Middle Name:MARIEA
Other - Last Name:NOEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:5471 DR MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-4265
Mailing Address - Country:US
Mailing Address - Phone:314-367-5820
Mailing Address - Fax:314-367-6326
Practice Address - Street 1:5471 DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-4265
Practice Address - Country:US
Practice Address - Phone:314-367-5820
Practice Address - Fax:314-367-6326
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002013492164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse