Healthcare Provider Details

I. General information

NPI: 1609361872
Provider Name (Legal Business Name): FAYTH-AN HOPE GRAY DNP, APRN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FAYTH-AN HOPE GOLDSBERRY

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10321 N 2274 RD
CLINTON OK
73601-7521
US

IV. Provider business mailing address

10321 N 2274 RD
CLINTON OK
73601-7521
US

V. Phone/Fax

Practice location:
  • Phone: 580-331-3300
  • Fax:
Mailing address:
  • Phone: 580-331-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0086086
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0086086
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: