Provider Demographics
NPI:1063669687
Name:GRAY, ALLYSON RAE (LPN)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:RAE
Last Name:GRAY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 ELM AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4001
Mailing Address - Country:US
Mailing Address - Phone:540-345-9841
Mailing Address - Fax:540-527-8900
Practice Address - Street 1:301 ELM AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4001
Practice Address - Country:US
Practice Address - Phone:540-345-9841
Practice Address - Fax:540-527-8900
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002051197164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437137734Medicaid