Provider Demographics
NPI:1376811737
Name:GRAY, STEPHANIE ANN (RD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:GRAY
Suffix:
Gender:F
Credentials:RD
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 173
Mailing Address - Street 2:210 W BRANSON STREET
Mailing Address - City:LA FONTAINE
Mailing Address - State:IN
Mailing Address - Zip Code:46940-0173
Mailing Address - Country:US
Mailing Address - Phone:260-571-5221
Mailing Address - Fax:
Practice Address - Street 1:441 N WABASH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2612
Practice Address - Country:US
Practice Address - Phone:765-660-6690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered