Provider Demographics
NPI:1619573870
Name:SEWELL-GRAY, YAREESHA VONSHAY
Entity Type:Individual
Prefix:
First Name:YAREESHA
Middle Name:VONSHAY
Last Name:SEWELL-GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 BRANTLEY RD APT 911
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3917
Mailing Address - Country:US
Mailing Address - Phone:239-265-1756
Mailing Address - Fax:
Practice Address - Street 1:11600 GLADIOLUS DR STE 102
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4565
Practice Address - Country:US
Practice Address - Phone:239-466-9454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH22958124Q00000X
FL22958124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22958Medicaid