Healthcare Provider Details

I. General information

NPI: 1669164935
Provider Name (Legal Business Name): TANIKA MICHELLE GRAY PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12183 MS HIGHWAY 182 STE 108
STARKVILLE MS
39759-1653
US

IV. Provider business mailing address

PO BOX 520
MARION MS
39342-0520
US

V. Phone/Fax

Practice location:
  • Phone: 662-268-7100
  • Fax: 662-268-6080
Mailing address:
  • Phone: 662-268-7100
  • Fax: 601-268-6080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number905999
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: