Provider Demographics
NPI:1588313712
Name:TRAY, NICKOLE REBECCA
Entity type:Individual
Prefix:
First Name:NICKOLE
Middle Name:REBECCA
Last Name:TRAY
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 1:1234 PINE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PERKIOMENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18074-9456
Mailing Address - Country:US
Mailing Address - Phone:610-283-2482
Mailing Address - Fax:
Practice Address - Street 1:960 HARVEST DRIVE
Practice Address - Street 2:#A SUITE 100
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-0009
Practice Address - Country:US
Practice Address - Phone:610-825-9360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN100838L164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse