Healthcare Provider Details

I. General information

NPI: 1538081997
Provider Name (Legal Business Name): KEELY JEAN GRAY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 HIGHWAY 90 N
RAVENDEN AR
72459-9091
US

IV. Provider business mailing address

745 HIGHWAY 90 N
RAVENDEN AR
72459-9091
US

V. Phone/Fax

Practice location:
  • Phone: 870-810-0370
  • Fax:
Mailing address:
  • Phone: 870-810-0370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL059580
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: