Healthcare Provider Details

I. General information

NPI: 1124385752
Provider Name (Legal Business Name): NICOLE K GRAY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DODDS AVE
CHATTANOOGA TN
37404-3911
US

IV. Provider business mailing address

1431 CENTERPOINT BLVD SUITE 100
KNOXVILLE TN
37932-1984
US

V. Phone/Fax

Practice location:
  • Phone: 423-453-8999
  • Fax: 866-401-5838
Mailing address:
  • Phone: 865-539-8000
  • Fax: 865-985-7077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2161
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: