Provider Demographics
NPI:1790395051
Name:BRAY, JACQUELINE MORIAH (DNP-FNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MORIAH
Last Name:BRAY
Suffix:
Gender:F
Credentials:DNP-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 FLYNN AVE STE 3J
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5420
Mailing Address - Country:US
Mailing Address - Phone:802-488-6934
Mailing Address - Fax:802-488-6919
Practice Address - Street 1:172 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1743
Practice Address - Country:US
Practice Address - Phone:802-488-6290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0134606363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT101.0134606OtherAPRN CREDENTIAL