Healthcare Provider Details

I. General information

NPI: 1174453153
Provider Name (Legal Business Name): AMANDA SUE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 FULTON AVE
CINCINNATI OH
45206-2504
US

IV. Provider business mailing address

2804 RIDGEFIELD DR
HEBRON KY
41048-9352
US

V. Phone/Fax

Practice location:
  • Phone: 513-221-1609
  • Fax:
Mailing address:
  • Phone: 859-443-6323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number002899
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: