Healthcare Provider Details

I. General information

NPI: 1699379636
Provider Name (Legal Business Name): SHALANE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3874 VISCOUNT AVE #3
MEMPHIS TN
38118
US

IV. Provider business mailing address

3874 VISCOUNT AVE #3
MEMPHIS TN
38118
US

V. Phone/Fax

Practice location:
  • Phone: 901-727-8684
  • Fax:
Mailing address:
  • Phone: 901-727-8684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License NumberL000000027082
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: