Basic Information
| Provider Information | |||||||||
| NPI: | 1538462197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | JODY | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | JODY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 719 | ||||||||
| Address2: | |||||||||
| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989440719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098371602 | ||||||||
| FaxNumber: | 5098374908 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 S 8TH ST | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989013020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094544143 | ||||||||
| FaxNumber: | 5094543651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2010 | ||||||||
| LastUpdateDate: | 09/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP60202580 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | G8899381 | 01 | MEDICARE PTAN | OTHER |