MEDICARE: MRS. SUSAN KAY GRAY FNP

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	41-207013	IL

General Provider Information

NPI Number	:	1770616559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN KAY GRAY FNP

Provider Business Mailing Address
First Line	:	PO BOX 77
Second Line	:	109 N CHESTNUT
City	:	ONARGA
State	:	IL
Zip	:	60955
Country	:	US
Telephone Number	:	815-268-4840
Fax Number	:	815-268-4845

Provider Business Practice Location Address
First Line	:	109 N CHESTNUT
Second Line	:
City	:	ONARGA
State	:	IL
Zip	:	60955
Country	:	US
Telephone Number	:	815-268-4840
Fax Number	:	815-268-4845

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

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	12/12/2012

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