Provider Demographics
NPI:1699153221
Name:RAY, YVONNE
Entity type:Individual
Prefix:
First Name:YVONNE
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 1:1015 GALLOWAY AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-1203
Mailing Address - Country:US
Mailing Address - Phone:210-382-0010
Mailing Address - Fax:214-758-0247
Practice Address - Street 1:1015 GALLOWAY AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-1203
Practice Address - Country:US
Practice Address - Phone:210-382-0010
Practice Address - Fax:214-758-0247
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX743026515251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX743026515Medicaid