Provider Demographics
NPI:1528193372
Name:GREY, DE'SHANTEL (LPN)
Entity Type:Individual
Prefix:MS
First Name:DE'SHANTEL
Middle Name:
Last Name:GREY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 STOCKBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1707
Mailing Address - Country:US
Mailing Address - Phone:716-259-9321
Mailing Address - Fax:
Practice Address - Street 1:489 STOCKBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1707
Practice Address - Country:US
Practice Address - Phone:716-259-9321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284787164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse