Provider Demographics
NPI:1598786097
Name:GRAY, STEPHANIE R (ARNP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:R
Last Name:GRAY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 642117
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-8117
Mailing Address - Country:US
Mailing Address - Phone:402-398-6255
Mailing Address - Fax:402-829-8513
Practice Address - Street 1:801 HARMONY ST
Practice Address - Street 2:SUITE 302
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-3106
Practice Address - Country:US
Practice Address - Phone:712-328-2609
Practice Address - Fax:712-328-9257
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA098610363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI87040089OtherMEDICARE PTAN