Provider Demographics
NPI:1518904374
Name:GRAY, KATHRYN A (RN, FNP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:GRAY
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2345
Mailing Address - Country:US
Mailing Address - Phone:231-935-6520
Mailing Address - Fax:231-935-9116
Practice Address - Street 1:1105 6TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2345
Practice Address - Country:US
Practice Address - Phone:231-935-6520
Practice Address - Fax:231-935-9116
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704116935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3521244Medicaid
MI500B814150OtherBLUE CROSS GROUP PRACTICE PIN
MI4704116935OtherLICENSE
MI4704116935OtherLICENSE
MI0P24420Medicare PIN
MAMG0964494OtherDEA
MIS69715Medicare UPIN
MI3521244Medicaid