Provider Demographics
NPI:1447649975
Name:WRAY, SHELLEY S (NP)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:S
Last Name:WRAY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 E GALA ST STE 3
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7692
Mailing Address - Country:US
Mailing Address - Phone:208-888-5848
Mailing Address - Fax:208-888-0884
Practice Address - Street 1:2321 E GALA ST STE 3
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7692
Practice Address - Country:US
Practice Address - Phone:208-888-5848
Practice Address - Fax:208-888-0884
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1476A363LP0808X
IDNP-1746A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1447649975Medicaid
ID1447649975Medicaid