Provider Demographics
NPI:1447600077
Name:GRAY, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
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 1:1513 CHATHAM CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1665 KINGSLEY AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4490
Practice Address - Country:US
Practice Address - Phone:904-579-3704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5149237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist