Basic Information
| Provider Information | |||||||||
| NPI: | 1447649975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WRAY | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2321 E GALA ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836427692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088885848 | ||||||||
| FaxNumber: | 2088880884 | ||||||||
| Practice Location | |||||||||
| Address1: | 2321 E GALA ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836427692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088885848 | ||||||||
| FaxNumber: | 2088880884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2015 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | NP-1476A | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | NP-1746A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1447649975 | 05 | ID | MEDICAID |