Healthcare Provider Details

I. General information

NPI: 1669735288
Provider Name (Legal Business Name): ROSA LEE GRAY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 BIENVILLE CIR
NATCHITOCHES LA
71457-5744
US

IV. Provider business mailing address

121 LAURYN ST
NATCHITOCHES LA
71457-5330
US

V. Phone/Fax

Practice location:
  • Phone: 318-357-3132
  • Fax: 318-357-3136
Mailing address:
  • Phone: 318-357-3132
  • Fax: 318-357-3136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number075080
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: