Provider Demographics
NPI:1497308936
Name:RAY, KATELYN (FNP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:RAY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1617 SIERRA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-6610
Mailing Address - Country:US
Mailing Address - Phone:562-899-1956
Mailing Address - Fax:
Practice Address - Street 1:3800 E COAST HWY STE 2
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2548
Practice Address - Country:US
Practice Address - Phone:949-432-5863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012252363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily