Provider Demographics
NPI:1124346994
Name:PRAY, MANDELYNN GRACE ANN (CNM)
Entity type:Individual
Prefix:MRS
First Name:MANDELYNN
Middle Name:GRACE ANN
Last Name:PRAY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:MANDELYNN
Other - Middle Name:GRACE ANN
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1520
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-8003
Mailing Address - Country:US
Mailing Address - Phone:541-298-7971
Mailing Address - Fax:541-296-6431
Practice Address - Street 1:1810 E 19TH ST
Practice Address - Street 2:SUITE 209
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3388
Practice Address - Country:US
Practice Address - Phone:541-296-5657
Practice Address - Fax:541-298-5199
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAWARDED JUNE 2010367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500624408Medicaid
ORR172547Medicare PIN