Healthcare Provider Details

I. General information

NPI: 1992234355
Provider Name (Legal Business Name): MS. ANGELA GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 06/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3941 AMANDA COURT
BIRMINGHAM AL
35215
US

IV. Provider business mailing address

3941 AMANDA CT
CENTER POINT AL
35215-2625
US

V. Phone/Fax

Practice location:
  • Phone: 205-305-5841
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number17020904
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: