Provider Demographics
NPI:1619756855
Name:GRAY, VIRGINIA M
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:M
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 1:111 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4310
Mailing Address - Country:US
Mailing Address - Phone:901-340-1700
Mailing Address - Fax:
Practice Address - Street 1:518 WOODLAND VIEW DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-2834
Practice Address - Country:US
Practice Address - Phone:190-134-0170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist