Provider Demographics
NPI:1831911536
Name:GRAY, NICOLE LYNN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name: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 1:413 NW 3RD ST
Mailing Address - Street 2:413 NW 3RD STREET
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754
Mailing Address - Country:US
Mailing Address - Phone:541-291-3488
Mailing Address - Fax:
Practice Address - Street 1:413 NW 3RD ST
Practice Address - Street 2:413 NW 3RD ST
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754
Practice Address - Country:US
Practice Address - Phone:541-291-3488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORNT-10189794156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist