Provider Demographics
NPI:1548953649
Name:GRAY, ALICIA MARIE
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
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 1:306 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1860
Mailing Address - Country:US
Mailing Address - Phone:509-758-9470
Mailing Address - Fax:509-758-9478
Practice Address - Street 1:306 5TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-1860
Practice Address - Country:US
Practice Address - Phone:509-758-9470
Practice Address - Fax:509-758-9478
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO60207564156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician