Healthcare Provider Details

I. General information

NPI: 1821388034
Provider Name (Legal Business Name): MARCELLA GEVONNE WILLIS-GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARCELLA GEVONNE WILLIS

II. Dates (important events)

Enumeration Date: 04/10/2011
Last Update Date: 05/03/2025
Certification Date: 05/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3032 OLD CLINIC BLDG CB#7570
CHAPEL HILL NC
27599-7570
US

IV. Provider business mailing address

4325 LAKE BOONE TRL
RALEIGH NC
27607-7509
US

V. Phone/Fax

Practice location:
  • Phone: 919-966-4717
  • Fax:
Mailing address:
  • Phone: 984-974-0498
  • Fax: 984-974-0497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number2015-00256
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number2015-00256
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: