MEDICARE: MRS. NICOLA JAYNE WRAY PCD, CLC

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	174N00000X	Lactation Consultant (Non-RN)	207105	PA
2	374J00000X	Doula

General Provider Information

NPI Number	:	1356715056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLA JAYNE WRAY PCD, CLC

Provider Business Mailing Address
First Line	:	1200 FIRST ST
Second Line	:	APT 425
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-1676
Country	:	US
Telephone Number	:	703-606-6033
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 FIRST ST
Second Line	:	APT 425
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-1676
Country	:	US
Telephone Number	:	703-606-6033
Fax Number	:

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

Provider Enumeration Date	:	11/18/2015
Last Update Date	:	11/18/2015

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