Provider Demographics
NPI:1497893440
Name:GRAY, CATHERINE J (FNP)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:J
Last Name:GRAY
Suffix:
Gender:F
Credentials:FNP
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 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:608 CITY ROUTE 66
Practice Address - Street 2:
Practice Address - City:ST. ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584
Practice Address - Country:US
Practice Address - Phone:573-336-5100
Practice Address - Fax:573-336-3118
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO095237363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO423104439Medicaid
MOP89730Medicare UPIN
MO423104439Medicaid