Provider Demographics
NPI:1972994259
Name:WALLER-RAY, KITTY (BSN, RN)
Entity Type:Individual
Prefix:
First Name:KITTY
Middle Name:
Last Name:WALLER-RAY
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2667 WALLER RD
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:KY
Mailing Address - Zip Code:41092-9222
Mailing Address - Country:US
Mailing Address - Phone:859-620-9247
Mailing Address - Fax:
Practice Address - Street 1:2667 WALLER RD
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:KY
Practice Address - Zip Code:41092-9222
Practice Address - Country:US
Practice Address - Phone:859-620-9247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.218940163W00000X
IN28108139163W00000X
KY1059158163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse