Healthcare Provider Details

I. General information

NPI: 1801078423
Provider Name (Legal Business Name): MARTA R GRAY F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 OLIVE ST STE 400
SAINT LOUIS MO
63103-2303
US

IV. Provider business mailing address

1430 OLIVE ST STE 400
SAINT LOUIS MO
63103-2303
US

V. Phone/Fax

Practice location:
  • Phone: 314-206-3700
  • Fax:
Mailing address:
  • Phone: 314-206-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number2003018738
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2003018738
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: