Provider Demographics
NPI:1396748901
Name:RAY, MARY JO (ARNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:RAY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-3452
Mailing Address - Country:US
Mailing Address - Phone:319-524-5734
Mailing Address - Fax:319-524-5758
Practice Address - Street 1:400 N 17TH ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3452
Practice Address - Country:US
Practice Address - Phone:319-524-5734
Practice Address - Fax:319-524-5758
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC076938363LP0200X
IL041-138505363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429203201Medicaid
421527584OtherTRI-CARE GROUP NUMBER
42152758405OtherJOHN DEERE
IL421527584003Medicaid
33627OtherBLUE CROSS BLUE SHIELD
IAO278374Medicaid
I7911Medicare ID - Type UnspecifiedMEDICARE B
161816Medicare ID - Type UnspecifiedMEDICARE UGS
IL421527584003Medicaid