Healthcare Provider Details

I. General information

NPI: 1962349035
Provider Name (Legal Business Name): TRIVERR GRAY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 SHALLOW BROOK WAY
LA PLATA MD
20646-3261
US

IV. Provider business mailing address

116 SHALLOW BROOK WAY
LA PLATA MD
20646-3261
US

V. Phone/Fax

Practice location:
  • Phone: 804-241-4379
  • Fax:
Mailing address:
  • Phone: 804-241-4379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberR266401
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: