Healthcare Provider Details

I. General information

NPI: 1578062576
Provider Name (Legal Business Name): CRYSTAL ANN GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 BILL FRANCE BLVD STE 200
DAYTONA BEACH FL
32114-1316
US

IV. Provider business mailing address

3041 GREEN ACRES RD
SAINT AUGUSTINE FL
32084-0849
US

V. Phone/Fax

Practice location:
  • Phone: 386-868-1992
  • Fax:
Mailing address:
  • Phone: 904-347-9476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: