Provider Demographics
NPI:1609829472
Name:HARRIS-RAY, NICKLYA M (DPM)
Entity Type:Individual
Prefix:DR
First Name:NICKLYA
Middle Name:M
Last Name:HARRIS-RAY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 HARDY COURT CTR
Mailing Address - Street 2:STE 136
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-2501
Mailing Address - Country:US
Mailing Address - Phone:786-395-1573
Mailing Address - Fax:
Practice Address - Street 1:505 ROBERT BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-1645
Practice Address - Country:US
Practice Address - Phone:786-395-1573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4806213E00000X
LADPM200002213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1582671Medicaid
LAP00440632OtherMEDICARE RAILROAD
LAP00440632OtherMEDICARE RAILROAD
LA$$$$$$$$$0OtherBLUE CROSS
LA6177960001Medicare NSC