Provider Demographics
NPI:1144417692
Name:GRAY, MARY LOUISE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
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 1:902 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2210
Mailing Address - Country:US
Mailing Address - Phone:618-937-6483
Mailing Address - Fax:618-937-1440
Practice Address - Street 1:3111 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5235
Practice Address - Country:US
Practice Address - Phone:618-997-3647
Practice Address - Fax:618-969-9437
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-142634163WP0808X
IL041.142634163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse