MEDICARE: MRS. LEANDRA JORDAN GRAY NP-C

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	363LF0000X	Family Nurse Practitioner	18185	OH

General Provider Information

NPI Number	:	1629448956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LEANDRA JORDAN GRAY NP-C

Provider Business Mailing Address
First Line	:	3170 KETTERING BLVD BLDG B3
Second Line	:
City	:	MORAINE
State	:	OH
Zip	:	45439-1924
Country	:	US
Telephone Number	:	937-991-3189
Fax Number	:	931-223-9811

Provider Business Practice Location Address
First Line	:	51 S STANFIELD RD
Second Line	:
City	:	TROY
State	:	OH
Zip	:	45373-2992
Country	:	US
Telephone Number	:	937-335-2722
Fax Number	:

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

Provider Enumeration Date	:	09/29/2015
Last Update Date	:	09/10/2018

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