Provider Demographics
NPI:1467951491
Name:GRAY, KELLY L (FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:GRAY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21410 N 19TH AVE STE 114
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-2755
Mailing Address - Country:US
Mailing Address - Phone:480-589-2890
Mailing Address - Fax:480-436-6599
Practice Address - Street 1:21410 N 19TH AVE STE 114
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-2755
Practice Address - Country:US
Practice Address - Phone:480-589-2890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN155353163W00000X
AZAP11572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse