Provider Demographics
NPI:1285825893
Name:GRAY, RONDA ANNE (ARNP)
Entity Type:Individual
Prefix:
First Name:RONDA
Middle Name:ANNE
Last Name:GRAY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W MAPLE AVE
Mailing Address - Street 2:SUITE 403
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-5335
Mailing Address - Country:US
Mailing Address - Phone:479-750-2742
Mailing Address - Fax:479-750-2781
Practice Address - Street 1:601 W MAPLE AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5335
Practice Address - Country:US
Practice Address - Phone:479-750-2742
Practice Address - Fax:479-750-2781
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO126049364S00000X
ARS02253364SP0807X, 364SP0809X
KS53-74557-012363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR4A107Medicare PIN