Provider Demographics
NPI:1558817668
Name:GRAY, BRECKIN SKYE (FNP)
Entity Type:Individual
Prefix:
First Name:BRECKIN
Middle Name:SKYE
Last Name:GRAY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FOUNTAINS BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6344
Mailing Address - Country:US
Mailing Address - Phone:601-707-7026
Mailing Address - Fax:
Practice Address - Street 1:111 FOUNTAINS BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6344
Practice Address - Country:US
Practice Address - Phone:601-707-7026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901727363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily