Provider Demographics
NPI:1619729613
Name:GRAY, SHELLY ANN (CMA)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN
Last Name:GRAY
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21621 LOGSDEN RD
Mailing Address - Street 2:
Mailing Address - City:BLODGETT
Mailing Address - State:OR
Mailing Address - Zip Code:97326-9343
Mailing Address - Country:US
Mailing Address - Phone:503-451-1969
Mailing Address - Fax:
Practice Address - Street 1:36 SW NYE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3821
Practice Address - Country:US
Practice Address - Phone:541-265-4947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-03
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR728012376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide