Healthcare Provider Details

I. General information

NPI: 1982123717
Provider Name (Legal Business Name): VICTORIA ELIZABETH GRAY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19448 111TH RD
SAINT ALBANS NY
11412-2019
US

IV. Provider business mailing address

300 COMMUNITY DR
MANHASSET NY
11030-3816
US

V. Phone/Fax

Practice location:
  • Phone: 917-573-3619
  • Fax: 929-333-9664
Mailing address:
  • Phone: 516-562-4290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number340876
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: