Provider Demographics
NPI:1760409346
Name:RAY, SHELLEY LENORE (CNM)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:LENORE
Last Name:RAY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:900 TOWNE LAKE PKWY
Mailing Address - Street 2:STE 404
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-1602
Mailing Address - Country:US
Mailing Address - Phone:770-926-9229
Mailing Address - Fax:678-415-2164
Practice Address - Street 1:900 TOWNE LAKE PKWY
Practice Address - Street 2:STE 404
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-1602
Practice Address - Country:US
Practice Address - Phone:770-926-9229
Practice Address - Fax:678-415-2164
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN124867367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000876213AMedicaid
GA000876213EMedicaid
GA000876213FMedicaid
GA340885OtherWELLCARE
GA10045510OtherAMERIGROUP
GA000876213FMedicaid