Provider Demographics
NPI:1275521809
Name:BRAY, KIRSTEN NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:NICOLE
Last Name:BRAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98313
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27624-8313
Mailing Address - Country:US
Mailing Address - Phone:919-845-0054
Mailing Address - Fax:919-845-1947
Practice Address - Street 1:1617 W GARRISON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-3635
Practice Address - Country:US
Practice Address - Phone:704-867-0219
Practice Address - Fax:704-867-0216
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2001-003152084A0401X
NC200100315207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8910429Medicaid
NC2203841EMedicare ID - Type Unspecified