Provider Demographics
NPI:1720404718
Name:CORDRAY, CAROLYN JO
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JO
Last Name:CORDRAY
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 1:6209 RIVERVIEW DR NW
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:OH
Mailing Address - Zip Code:44644-9677
Mailing Address - Country:US
Mailing Address - Phone:330-863-6339
Mailing Address - Fax:
Practice Address - Street 1:6209 RIVERVIEW DR NW
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:OH
Practice Address - Zip Code:44644-9677
Practice Address - Country:US
Practice Address - Phone:330-863-6339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2273441374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2273441Medicaid