Healthcare Provider Details

I. General information

NPI: 1760301782
Provider Name (Legal Business Name): SHANQUALE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11616 SOUTHFORK AVE
BATON ROUGE LA
70816-5241
US

IV. Provider business mailing address

5304 SILVERLEAF AVE
BATON ROUGE LA
70812-2041
US

V. Phone/Fax

Practice location:
  • Phone: 225-261-7143
  • Fax:
Mailing address:
  • Phone: 225-620-6311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: