Healthcare Provider Details

I. General information

NPI: 1902113327
Provider Name (Legal Business Name): MARYANN GRAY BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W ANTLER AVE
REDMOND OR
97756-2129
US

IV. Provider business mailing address

PO BOX 1108 ACP 0016-07
SALEM OR
97308-1108
US

V. Phone/Fax

Practice location:
  • Phone: 541-316-2041
  • Fax:
Mailing address:
  • Phone: 541-447-5877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: