Provider Demographics
NPI:1588242952
Name:RAY, BREANNA BETH (MA, RD)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:BETH
Last Name:RAY
Suffix:
Gender:F
Credentials:MA, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 WASHINGTON AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7724
Mailing Address - Country:US
Mailing Address - Phone:616-395-2833
Mailing Address - Fax:
Practice Address - Street 1:904 WASHINGTON AVE STE 210
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7724
Practice Address - Country:US
Practice Address - Phone:616-395-2833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered