Basic Information
| Provider Information | |||||||||
| NPI: | 1669453643 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAY | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | C.R.N.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 KIMEL PARK DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367683212 | ||||||||
| FaxNumber: | 3367689019 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 KIMEL PARK DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367683212 | ||||||||
| FaxNumber: | 3367689019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 058311 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 033611 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 8050072 | 05 | NC | MEDICAID | 260054Q | 01 | NC | PSC MEDICARE PROVIDER # | OTHER |