Healthcare Provider Details

I. General information

NPI: 1386248375
Provider Name (Legal Business Name): ANGELA NECHELLE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 WESTROCK FARM DR
ENGLEWOOD OH
45322-2945
US

IV. Provider business mailing address

109 WESTROCK FARM DR
ENGLEWOOD OH
45322-2945
US

V. Phone/Fax

Practice location:
  • Phone: 937-751-2566
  • Fax:
Mailing address:
  • Phone: 937-751-2566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberRV332116
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License NumberRV332116
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License NumberRV332116
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberRV332116
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: