Healthcare Provider Details

I. General information

NPI: 1225956352
Provider Name (Legal Business Name): TIFFANY ROSE GRAY
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N181 STATE RD 108
MELROSE WI
54642
US

IV. Provider business mailing address

N181 STATE RD 108
MELROSE WI
54642
US

V. Phone/Fax

Practice location:
  • Phone: 608-488-2201
  • Fax: 608-506-1094
Mailing address:
  • Phone: 608-488-2201
  • Fax: 608-506-1094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number222331-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: