Healthcare Provider Details

I. General information

NPI: 1831759547
Provider Name (Legal Business Name): TRACI GRAY AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 CARPENTER ST
JENA LA
71342-7143
US

IV. Provider business mailing address

307 CARPENTER ST
JENA LA
71342-7143
US

V. Phone/Fax

Practice location:
  • Phone: 318-481-5724
  • Fax: 318-257-1468
Mailing address:
  • Phone: 318-481-5724
  • Fax: 318-257-1468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number206362
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number206362
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: