Healthcare Provider Details

I. General information

NPI: 1063873222
Provider Name (Legal Business Name): SUSAN JO GRAY APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN JO WANDERMAN RN

II. Dates (important events)

Enumeration Date: 03/16/2016
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 HIGHWAY 31 STE 100
FLEMINGTON NJ
08822-5773
US

IV. Provider business mailing address

215 STATE ROUTE 31 RM 116
FLEMINGTON NJ
08822-5752
US

V. Phone/Fax

Practice location:
  • Phone: 908-788-6654
  • Fax:
Mailing address:
  • Phone: 908-284-1125
  • Fax: 908-284-2016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number26NJ00604400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number26NJ00604400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: