MEDICARE: ANGELA JO 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	207VC0300X	Complex Family Planning Physician	1205242120	IL
2	363LF0000X	Family Nurse Practitioner	209022716	IL

General Provider Information

NPI Number	:	1952027518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA JO GRAY FNP

Provider Business Mailing Address
First Line	:	111 OAKWOOD RD
Second Line	:
City	:	EAST PEORIA
State	:	IL
Zip	:	61611-1853
Country	:	US
Telephone Number	:	309-740-4272
Fax Number	:

Provider Business Practice Location Address
First Line	:	530 NE GLEN OAK AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61637-0001
Country	:	US
Telephone Number	:	309-655-2000
Fax Number	:

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

Provider Enumeration Date	:	10/17/2022
Last Update Date	:	06/11/2024

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