MEDICARE: MELANIE LYNN GRAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374J00000X	Doula

General Provider Information

NPI Number	:	1447672118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELANIE LYNN GRAY

Provider Business Mailing Address
First Line	:	14160 SHADY BEACH TRL NE
Second Line	:
City	:	PRIOR LAKE
State	:	MN
Zip	:	55372-1364
Country	:	US
Telephone Number	:	651-328-7699
Fax Number	:

Provider Business Practice Location Address
First Line	:	14160 SHADY BEACH TRL NE
Second Line	:
City	:	PRIOR LAKE
State	:	MN
Zip	:	55372-1364
Country	:	US
Telephone Number	:	651-328-7699
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2014
Last Update Date	:	01/14/2014

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