Healthcare Provider Details

I. General information

NPI: 1033651203
Provider Name (Legal Business Name): AM GRAY CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44125 WOODRIDGE PKWY SUITE 220
LEESBURG VA
20176-6839
US

IV. Provider business mailing address

44125 WOODRIDGE PKWY SUITE 220
LEESBURG VA
20176-6839
US

V. Phone/Fax

Practice location:
  • Phone: 703-539-6002
  • Fax: 703-439-2829
Mailing address:
  • Phone: 703-539-6002
  • Fax: 703-439-2829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024173992
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number28154063A
License Number StateIN

VIII. Authorized Official

Name: LASONDRA GRAY
Title or Position: MANAGING MEMBER
Credential:
Phone: 571-337-3870