Healthcare Provider Details

I. General information

NPI: 1336964071
Provider Name (Legal Business Name): KYLA CAMILLE GRAY MSN, FNP-C, PMHNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15422 N 172ND LN
SURPRISE AZ
85388-0238
US

IV. Provider business mailing address

15422 N 172ND LN
SURPRISE AZ
85388-0238
US

V. Phone/Fax

Practice location:
  • Phone: 708-915-9072
  • Fax:
Mailing address:
  • Phone: 708-915-9072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License NumberRN230797
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN230797
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: