Healthcare Provider Details

I. General information

NPI: 1972104479
Provider Name (Legal Business Name): ELIZABETH ROSE GRAY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH ROSE FERGUSON

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SIVLEY RD SW
HUNTSVILLE AL
35801-4470
US

IV. Provider business mailing address

112 OAKSIDE CIR NW
MADISON AL
35757-4201
US

V. Phone/Fax

Practice location:
  • Phone: 256-265-7677
  • Fax: 256-265-7677
Mailing address:
  • Phone: 334-718-9588
  • Fax: 256-265-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number1-146153
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1-146153
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: