Basic Information
| Provider Information | |||||||||
| NPI: | 1154969202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAY | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | LAUREL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PMHNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALKER | ||||||||
| OtherFirstName: | VANESSA | ||||||||
| OtherMiddleName: | LAUREL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PMHNP-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1668 | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985845001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604262653 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1701 N 13TH ST | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985842077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604262653 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2019 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | AP61014412 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.