Healthcare Provider Details

I. General information

NPI: 1952923559
Provider Name (Legal Business Name): STEPHANIE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 LIPAN HWY LOT 39
GRANBURY TX
76048-4269
US

IV. Provider business mailing address

2700 LIPAN HWY LOT 39
GRANBURY TX
76048-4269
US

V. Phone/Fax

Practice location:
  • Phone: 386-631-0022
  • Fax:
Mailing address:
  • Phone: 386-631-0022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number654303
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: