Provider Demographics
NPI:1285216358
Name:GRAY, NOLA CRYSTALYN
Entity Type:Individual
Prefix:
First Name:NOLA
Middle Name:CRYSTALYN
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 1:420 THOMSON CIR
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-5656
Mailing Address - Country:US
Mailing Address - Phone:864-366-3330
Mailing Address - Fax:864-366-4958
Practice Address - Street 1:420 THOMSON CIR
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29620-5656
Practice Address - Country:US
Practice Address - Phone:864-366-3330
Practice Address - Fax:864-366-4958
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist