Basic Information
| Provider Information | |||||||||
| NPI: | 1710228606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAY | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | RN, MSN CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913188 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 MOTE DR | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453181260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3720890109 | ||||||||
| FaxNumber: | 9372089020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2013 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN.293630 | OH | N | Nursing Service Providers | Registered Nurse | 363LF0000X | COA.14724-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0088383 | 05 | OH | MEDICAID |