Provider Demographics
NPI:1013588169
Name:GRAY, VANESSA ANNE (PTA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ANNE
Last Name:GRAY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5453 N MITCHUM AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-0004
Mailing Address - Country:US
Mailing Address - Phone:503-869-6843
Mailing Address - Fax:
Practice Address - Street 1:5453 N MITCHUM AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-0004
Practice Address - Country:US
Practice Address - Phone:503-869-6843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5287225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant