Provider Demographics
NPI:1376637900
Name:RAY, MARIA DIANE (RD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:DIANE
Last Name:RAY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:M
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:12204 WEST HOME ROAD
Mailing Address - Street 2:
Mailing Address - City:BRAMAN
Mailing Address - State:OK
Mailing Address - Zip Code:74632
Mailing Address - Country:US
Mailing Address - Phone:580-385-2377
Mailing Address - Fax:620-441-5953
Practice Address - Street 1:216 WEST BIRCH
Practice Address - Street 2:
Practice Address - City:ARKANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:67005-1107
Practice Address - Country:US
Practice Address - Phone:620-441-5722
Practice Address - Fax:620-441-5953
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS411133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS130477OtherBCBS
KS130477Medicaid
KS130477Medicaid
130477Medicare ID - Type Unspecified