Provider Demographics
NPI:1962448969
Name:GRAY, REBECCA LYNNE (APNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNNE
Last Name:GRAY
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNNE
Other - Last Name:WESTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, WHNP, CNM, FNP
Mailing Address - Street 1:5200 FAIRVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-8013
Mailing Address - Country:US
Mailing Address - Phone:651-982-7600
Mailing Address - Fax:
Practice Address - Street 1:5200 FAIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092
Practice Address - Country:US
Practice Address - Phone:651-982-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2615-33363L00000X
WI2615363LW0102X
MN303367A00000X, 363L00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2615OtherSTATE MEDICAL LICENSE
MT38168OtherSTATE MEDICAL LICENSE
WI106194OtherSTATE MEDICAL LICENSE
WI41265200Medicaid
MNR118279-4OtherSTATE MEDICAL LICENSE
Q45548Medicare UPIN
WI0037-49155Medicare ID - Type Unspecified