Provider Demographics
NPI:1629448956
Name:GRAY, LEANDRA JORDAN (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:LEANDRA
Middle Name:JORDAN
Last Name:GRAY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3189
Mailing Address - Fax:931-223-9811
Practice Address - Street 1:51 S STANFIELD RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2992
Practice Address - Country:US
Practice Address - Phone:937-335-2722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH18185363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily