Healthcare Provider Details

I. General information

NPI: 1275015257
Provider Name (Legal Business Name): SHELLEY GRAY DNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLEY GRAY DNP, FNP-C

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CHILD ST
JACKSONVILLE FL
32214-6122
US

IV. Provider business mailing address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

V. Phone/Fax

Practice location:
  • Phone: 843-228-5175
  • Fax:
Mailing address:
  • Phone: 843-228-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number198783
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAC003800
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: