Healthcare Provider Details

I. General information

NPI: 1023473493
Provider Name (Legal Business Name): KIMECA GRAY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2015
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 E 2ND ST
AUSTIN TX
78702-4490
US

IV. Provider business mailing address

213 ARABIAN COLT DR
GEORGETOWN TX
78626-2655
US

V. Phone/Fax

Practice location:
  • Phone: 512-703-1365
  • Fax:
Mailing address:
  • Phone: 254-371-0933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number967202
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number219741
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: