Provider Demographics
NPI:1114400884
Name:GRAY, MARY AMANDA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:AMANDA
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 BUCKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-4504
Mailing Address - Country:US
Mailing Address - Phone:757-814-6432
Mailing Address - Fax:
Practice Address - Street 1:5306 OLD VIRGINIA STREET
Practice Address - Street 2:
Practice Address - City:URBANNA
Practice Address - State:VA
Practice Address - Zip Code:23692
Practice Address - Country:US
Practice Address - Phone:757-814-6432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA885502133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered