Healthcare Provider Details

I. General information

NPI: 1235867821
Provider Name (Legal Business Name): MARISSA M GRAY DNP PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 POPLAR AVE STE 302
MEMPHIS TN
38117-4433
US

IV. Provider business mailing address

11530 SPRING MANOR LN
EADS TN
38028-7987
US

V. Phone/Fax

Practice location:
  • Phone: 901-651-5929
  • Fax:
Mailing address:
  • Phone: 901-651-5929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number210094
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number907923
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number230091
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number32604
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: