Healthcare Provider Details

I. General information

NPI: 1053145243
Provider Name (Legal Business Name): KATELYN ELIZABETH GRAY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 E REDSTONE AVE STE A
CRESTVIEW FL
32539-5350
US

IV. Provider business mailing address

801 TEE ST
NICEVILLE FL
32578-3019
US

V. Phone/Fax

Practice location:
  • Phone: 850-682-7212
  • Fax:
Mailing address:
  • Phone: 817-456-8685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11031841
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: