Provider Demographics
NPI:1912975558
Name:RAYMOND, MARY ELLEN (CNM)
Entity Type:Individual
Prefix:MRS
First Name:MARY ELLEN
Middle Name:
Last Name:RAYMOND
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 BLAUVELT WAY APT 612
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4528
Mailing Address - Country:US
Mailing Address - Phone:913-651-4617
Mailing Address - Fax:
Practice Address - Street 1:600 CAISSON HILL RD
Practice Address - Street 2:
Practice Address - City:FT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-7037
Practice Address - Country:US
Practice Address - Phone:785-239-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-64102-022367A00000X
NY002121367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1846884Medicaid