Healthcare Provider Details

I. General information

NPI: 1265165229
Provider Name (Legal Business Name): KIMBERLY GRAY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 AIRPORT PKWY
GREENWOOD IN
46143-1439
US

IV. Provider business mailing address

2382 E WINDING BROOK CIR
BLOOMINGTON IN
47401-4382
US

V. Phone/Fax

Practice location:
  • Phone: 317-887-1348
  • Fax:
Mailing address:
  • Phone: 812-327-2810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number28212858A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: