Healthcare Provider Details

I. General information

NPI: 1952027518
Provider Name (Legal Business Name): ANGELA JO GRAY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

111 OAKWOOD RD
EAST PEORIA IL
61611-1853
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-2000
  • Fax:
Mailing address:
  • Phone: 309-740-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209022716
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207VC0300X
TaxonomyComplex Family Planning Physician
License Number1205242120
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: