Provider Demographics
NPI:1144892787
Name:RAY, GLENN JEFFREY
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:JEFFREY
Last Name:RAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 LANCASTER CT APT A
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35209-4234
Mailing Address - Country:US
Mailing Address - Phone:770-655-1786
Mailing Address - Fax:
Practice Address - Street 1:705 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3818
Practice Address - Country:US
Practice Address - Phone:770-301-0858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN230986367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered