Healthcare Provider Details

I. General information

NPI: 1912975558
Provider Name (Legal Business Name): MARY ELLEN RAYMOND CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CAISSON HILL RD
FT RILEY KS
66442-7037
US

IV. Provider business mailing address

1930 EDGEWOOD DR
LEAVENWORTH KS
66048-1927
US

V. Phone/Fax

Practice location:
  • Phone: 785-239-7000
  • Fax:
Mailing address:
  • Phone: 913-651-4617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number53-64102-022
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: