Provider Demographics
NPI:1932593910
Name:RAY, SHONTEL MARLENA (AGPCNP)
Entity Type:Individual
Prefix:
First Name:SHONTEL
Middle Name:MARLENA
Last Name:RAY
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11133 DUNN RD STE 2427
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6163
Mailing Address - Country:US
Mailing Address - Phone:314-653-5643
Mailing Address - Fax:314-653-5648
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:STE 2427
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6163
Practice Address - Country:US
Practice Address - Phone:314-653-5643
Practice Address - Fax:314-653-5648
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013100363LA2200X
MO2015001948363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health