Provider Demographics
NPI:1932880333
Name:RAY, ELLEN
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
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:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6442
Mailing Address - Country:US
Mailing Address - Phone:636-229-3350
Mailing Address - Fax:636-229-3355
Practice Address - Street 1:4525 MID RIVERS MALL DR STE 10
Practice Address - Street 2:
Practice Address - City:COTTLEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63376-2820
Practice Address - Country:US
Practice Address - Phone:636-229-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005005840163WE0003X
MO2023033858363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WE0003XNursing Service ProvidersRegistered NurseEmergency