Healthcare Provider Details

I. General information

NPI: 1033841663
Provider Name (Legal Business Name): LYNETTE DELINA WRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4465 WILLARD AVE
CHEVY CHASE MD
20815-3605
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 301-951-3373
  • Fax: 301-951-3371
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP2000525
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2844
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: