Provider Demographics
NPI:1497976542
Name:GRAY, VALERIE
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 DOGWOOD HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-1707
Mailing Address - Country:US
Mailing Address - Phone:631-467-3921
Mailing Address - Fax:
Practice Address - Street 1:100 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3502
Practice Address - Country:US
Practice Address - Phone:631-265-7671
Practice Address - Fax:631-265-7692
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302139-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2E3661Medicare ID - Type Unspecified
NYP39047Medicare UPIN