Provider Demographics
NPI:1629012331
Name:GRAY, DEBORAH ELLIS (APN)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ELLIS
Last Name:GRAY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 24387
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37422
Mailing Address - Country:US
Mailing Address - Phone:423-648-8480
Mailing Address - Fax:423-648-8481
Practice Address - Street 1:2000 STEIN DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-7217
Practice Address - Country:US
Practice Address - Phone:423-648-8480
Practice Address - Fax:423-648-8481
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000005515363L00000X
GARN10078 NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4132006OtherBCBSTN
TN3908314Medicaid
TNP00320945Medicare PIN
P78458Medicare UPIN
GA50BBKRKMedicare PIN
TN3908314Medicaid