Provider Demographics
NPI:1578755286
Name:RAY, CAROLE A (CDR)
Entity Type:Individual
Prefix:MRS
First Name:CAROLE
Middle Name:A
Last Name:RAY
Suffix:
Gender:F
Credentials:CDR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N 400 E
Mailing Address - Street 2:
Mailing Address - City:PANGUITCH
Mailing Address - State:UT
Mailing Address - Zip Code:84759-0389
Mailing Address - Country:US
Mailing Address - Phone:435-676-8811
Mailing Address - Fax:435-676-1541
Practice Address - Street 1:200 N 400 E
Practice Address - Street 2:
Practice Address - City:PANGUITCH
Practice Address - State:UT
Practice Address - Zip Code:84759-0389
Practice Address - Country:US
Practice Address - Phone:435-676-8811
Practice Address - Fax:435-676-1541
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4825083-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4825083-4901OtherLICENSE #
UT32411Medicare UPIN