Provider Demographics
NPI:1447639737
Name:RAY, ILYA MELINA (FNP)
Entity type:Individual
Prefix:MRS
First Name:ILYA
Middle Name:MELINA
Last Name:RAY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:ILYA
Other - Middle Name:MELINA
Other - Last Name:COLLINSWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:12530 249TH CIR
Mailing Address - Street 2:
Mailing Address - City:TREVOR
Mailing Address - State:WI
Mailing Address - Zip Code:53179-9135
Mailing Address - Country:US
Mailing Address - Phone:262-298-5251
Mailing Address - Fax:
Practice Address - Street 1:12530 249TH CIR
Practice Address - Street 2:
Practice Address - City:TREVOR
Practice Address - State:WI
Practice Address - Zip Code:53179-9135
Practice Address - Country:US
Practice Address - Phone:262-298-5251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6368363LP0808X
WI6368-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily