Healthcare Provider Details

I. General information

NPI: 1043404833
Provider Name (Legal Business Name): TERESA DIANNE GRAY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 TROTWOOD AVE
COLUMBIA TN
38401-6406
US

IV. Provider business mailing address

1216 TROTWOOD AVE
COLUMBIA TN
38401-6406
US

V. Phone/Fax

Practice location:
  • Phone: 931-380-2532
  • Fax: 931-380-2596
Mailing address:
  • Phone: 931-380-2532
  • Fax: 931-380-2596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number0122784
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: