Healthcare Provider Details

I. General information

NPI: 1790130029
Provider Name (Legal Business Name): MARJORIE L REDD-GRAY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2016
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 DOOLITTLE AVE
FT WORTH TX
76127-1133
US

IV. Provider business mailing address

1711 DOOLITTLE AVE
FT WORTH TX
76127-1133
US

V. Phone/Fax

Practice location:
  • Phone: 469-449-3143
  • Fax:
Mailing address:
  • Phone: 469-449-3143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0416302
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP131025
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: