Provider Demographics
NPI:1043425796
Name:GRAY-WINFREY, WYLEA MARIE (NP)
Entity Type:Individual
Prefix:
First Name:WYLEA
Middle Name:MARIE
Last Name:GRAY-WINFREY
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 1:1217 WILLOW GLEN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71302-5454
Mailing Address - Country:US
Mailing Address - Phone:318-487-4400
Mailing Address - Fax:
Practice Address - Street 1:1217 WILLOW GLEN RIVER RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71302-5454
Practice Address - Country:US
Practice Address - Phone:318-487-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA020344363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1112585Medicaid
LAAP03533OtherADVANCE PRACTICE RN
LA1112585Medicaid