Healthcare Provider Details

I. General information

NPI: 1972810554
Provider Name (Legal Business Name): ABBY LYNN GRAY NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-2088
  • Fax: 208-381-2893
Mailing address:
  • Phone: 208-381-2088
  • Fax: 208-381-2893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberNP-1012A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: