MEDICARE: CARLA RAY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	187301	TN

General Provider Information

NPI Number	:	1205422698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA RAY RN

Provider Business Mailing Address
First Line	:	5343 PHILGROVE WAY
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38125-4138
Country	:	US
Telephone Number	:	901-870-7299
Fax Number	:

Provider Business Practice Location Address
First Line	:	5343 PHILGROVE WAY
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38125-4138
Country	:	US
Telephone Number	:	901-870-7299
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2020
Last Update Date	:	12/19/2020

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