Provider Demographics
NPI:1770397069
Name:RAY, JUSTINE MARIE
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:MARIE
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 1:102 DAVIS PL
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-7108
Mailing Address - Country:US
Mailing Address - Phone:217-473-7145
Mailing Address - Fax:
Practice Address - Street 1:102 DAVIS PL
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-7108
Practice Address - Country:US
Practice Address - Phone:217-473-7145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041535698163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse