Healthcare Provider Details

I. General information

NPI: 1467374363
Provider Name (Legal Business Name): KAITLYN ROSE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3211 PROVIDENCE DR # DRIVE211
ANCHORAGE AK
99508-4614
US

IV. Provider business mailing address

1275 PICKERING DR
FAIRBANKS AK
99709-5765
US

V. Phone/Fax

Practice location:
  • Phone: 907-786-6553
  • Fax:
Mailing address:
  • Phone: 907-378-6473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number213178
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: