Healthcare Provider Details

I. General information

NPI: 1568991925
Provider Name (Legal Business Name): PHADRA M GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6725 LEBANON ST
CINCINNATI OH
45216
US

IV. Provider business mailing address

6725 LEBANON ST
CINCINNATI OH
45216-2013
US

V. Phone/Fax

Practice location:
  • Phone: 513-242-0740
  • Fax:
Mailing address:
  • Phone: 513-242-0740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number431714
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: