Provider Demographics
NPI:1578062576
Name:GRAY, CRYSTAL ANN
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3041 GREEN ACRES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-0849
Mailing Address - Country:US
Mailing Address - Phone:904-347-9476
Mailing Address - Fax:
Practice Address - Street 1:259 BILL FRANCE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1316
Practice Address - Country:US
Practice Address - Phone:386-868-1992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator