Provider Demographics
NPI:1407945041
Name:GRAEY, COLLEEN LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:LYNN
Last Name:GRAEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2498
Mailing Address - Fax:208-262-7461
Practice Address - Street 1:1641 E POLSTON AVE STE 101
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7852
Practice Address - Country:US
Practice Address - Phone:208-457-4208
Practice Address - Fax:208-457-4197
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60811874363L00000X, 363L00000X
ID59685363L00000X
CA364110363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1407945041Medicaid
CARHM53963FMedicaid
CARHM53963FMedicaid