Healthcare Provider Details

I. General information

NPI: 1619490661
Provider Name (Legal Business Name): MISTI S GRAY WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 07/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2296 OPTIZ BLVD, SUITE 440 ABOUT WOMEN OB/GYN
WOODBRIDGE VA
22191
US

IV. Provider business mailing address

16410 STEDHAM CIRCLE APT 104
DUMFRIES VA
22025
US

V. Phone/Fax

Practice location:
  • Phone: 703-878-0740
  • Fax: 703-878-3933
Mailing address:
  • Phone: 757-325-7255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number0024174967
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number0024174967
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: