Healthcare Provider Details

I. General information

NPI: 1801680301
Provider Name (Legal Business Name): KRISSA BROOKE GRAY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2746 VIRGINIA AVE
LOUISVILLE KY
40211-3417
US

IV. Provider business mailing address

133 RIDGEWOOD CT
ELIZABETHTOWN KY
42701-7500
US

V. Phone/Fax

Practice location:
  • Phone: 502-815-7040
  • Fax:
Mailing address:
  • Phone: 270-734-1712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number1115652
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4039362
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: