Provider Demographics
NPI:1700522265
Name:RAY, LILLIANN EMMA
Entity Type:Individual
Prefix:
First Name:LILLIANN
Middle Name:EMMA
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 1:21 9TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1830
Mailing Address - Country:US
Mailing Address - Phone:701-212-8626
Mailing Address - Fax:
Practice Address - Street 1:921 2ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1705
Practice Address - Country:US
Practice Address - Phone:701-212-8626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND00000172A00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND172A0000XMedicaid
ND175T00000XMedicaid