Healthcare Provider Details

I. General information

NPI: 1851422646
Provider Name (Legal Business Name): MARY D. GRAY NP-P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 04/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137-50 JAMAICA AVE
JAMAICA NY
11435-3610
US

IV. Provider business mailing address

140 AMITY ST #2
BROOKLYN NY
11201-6107
US

V. Phone/Fax

Practice location:
  • Phone: 718-298-5100
  • Fax: 718-298-5130
Mailing address:
  • Phone: 718-855-2447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number379886-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: