MEDICARE: MARY NICOLE GRAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency		VA

General Provider Information

NPI Number	:	1467844670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY NICOLE GRAY

Provider Business Mailing Address
First Line	:	4645 SLIPPERY ROCK LN
Second Line	:
City	:	COLUMBIA
State	:	VA
Zip	:	23038-2325
Country	:	US
Telephone Number	:	434-390-9913
Fax Number	:

Provider Business Practice Location Address
First Line	:	4645 SLIPPERY ROCK LN
Second Line	:
City	:	COLUMBIA
State	:	VA
Zip	:	23038-2325
Country	:	US
Telephone Number	:	804-457-4153
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2015
Last Update Date	:	07/26/2017

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