Healthcare Provider Details

I. General information

NPI: 1831456888
Provider Name (Legal Business Name): AYANNA NATASHA GRAY-BOLDEN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CENTURIAN DR STE 312
NEWARK DE
19713-2127
US

IV. Provider business mailing address

1 CENTURIAN DR STE 312
NEWARK DE
19713-2127
US

V. Phone/Fax

Practice location:
  • Phone: 302-319-5680
  • Fax: 302-319-5681
Mailing address:
  • Phone: 302-319-5680
  • Fax: 302-319-5681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP011305
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: