Provider Demographics
NPI:1528574951
Name:GRAY, NICOLE LEE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:WALKAMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:13 SHELTON ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062-2041
Mailing Address - Country:US
Mailing Address - Phone:978-394-2410
Mailing Address - Fax:
Practice Address - Street 1:13 SHELTON ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03062-2041
Practice Address - Country:US
Practice Address - Phone:978-394-2410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN88310164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse