Healthcare Provider Details

I. General information

NPI: 1013689686
Provider Name (Legal Business Name): KIMBERLY GRAY FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/29/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 S 108TH ST
GREENFIELD WI
53228-1905
US

IV. Provider business mailing address

30815 ROYAL HILL RD
BURLINGTON WI
53105-7762
US

V. Phone/Fax

Practice location:
  • Phone: 262-716-5326
  • Fax:
Mailing address:
  • Phone: 262-716-5326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11507-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: