Provider Demographics
NPI:1548403629
Name:GRAY, MICHELLE L (FNP APRN-BC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:GRAY
Suffix:
Gender:F
Credentials:FNP APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 DOOLITTLE DR
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH AFB
Mailing Address - State:SD
Mailing Address - Zip Code:57706-4854
Mailing Address - Country:US
Mailing Address - Phone:605-385-3331
Mailing Address - Fax:
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:682-855-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138667363LF0000X
1710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians