Provider Demographics
NPI:1578686911
Name:GRAY, DARLA (LPN)
Entity Type:Individual
Prefix:
First Name:DARLA
Middle Name:
Last Name:GRAY
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 1:1515 S EXTENSION RD
Mailing Address - Street 2:APT. 1075
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-4973
Mailing Address - Country:US
Mailing Address - Phone:618-207-1075
Mailing Address - Fax:
Practice Address - Street 1:6000 S 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-4209
Practice Address - Country:US
Practice Address - Phone:602-243-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP041730164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse