Provider Demographics
NPI:1629768411
Name:RAY, KAYLIE M
Entity Type:Individual
Prefix:
First Name:KAYLIE
Middle Name:M
Last Name:RAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7538 ARDWELL DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9668
Mailing Address - Country:US
Mailing Address - Phone:317-945-6091
Mailing Address - Fax:
Practice Address - Street 1:1400 E HANNA AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-3697
Practice Address - Country:US
Practice Address - Phone:317-788-3368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2400-53-1479207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine