Provider Demographics
NPI:1275149767
Name:GRAY, JEREMY ROY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ROY
Last Name:GRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 BALLENTINE DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-8323
Mailing Address - Country:US
Mailing Address - Phone:919-740-1134
Mailing Address - Fax:
Practice Address - Street 1:1409 BALLENTINE DAIRY RD
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-8323
Practice Address - Country:US
Practice Address - Phone:919-740-1134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-20
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC86289495133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered