Provider Demographics
NPI:1952592792
Name:RAY, PHYLLIS (LMP)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:RAY
Suffix:
Gender:F
Credentials:LMP
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 314
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:WA
Mailing Address - Zip Code:99005-0314
Mailing Address - Country:US
Mailing Address - Phone:509-710-2938
Mailing Address - Fax:
Practice Address - Street 1:1713 E PROVIDENCE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-4553
Practice Address - Country:US
Practice Address - Phone:509-710-2938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022738174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist