Healthcare Provider Details

I. General information

NPI: 1285798280
Provider Name (Legal Business Name): JANNYSSE ELIZABETH GRAY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

4580 S LINDBERGH BLVD SOUTH COUNTY HEALTH CENTER
SAINT LOUIS MO
63127-1810
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 314-842-1300
  • Fax: 314-842-6431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number2005032433
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: