1124346994 NPI number — MRS. MANDELYNN GRACE ANN PRAY CNM

Table of content: MRS. MANDELYNN GRACE ANN PRAY CNM (NPI 1124346994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124346994 NPI number — MRS. MANDELYNN GRACE ANN PRAY CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRAY
Provider First Name:
MANDELYNN
Provider Middle Name:
GRACE ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MORGAN
Provider Other First Name:
MANDELYNN
Provider Other Middle Name:
GRACE ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124346994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1520
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THE DALLES
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97058-8003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-298-7971
Provider Business Mailing Address Fax Number:
541-296-6431

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1810 E 19TH ST
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
THE DALLES
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97058-3388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-296-5657
Provider Business Practice Location Address Fax Number:
541-298-5199
Provider Enumeration Date:
05/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  AWARDED JUNE 2010 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500624408 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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