Provider Demographics
NPI:1649412230
Name:GRAY-HARRIS, DORETT
Entity Type:Individual
Prefix:
First Name:DORETT
Middle Name:
Last Name:GRAY-HARRIS
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 1:54 SOUTH 2ND AVENUE
Mailing Address - Street 2:APT B-4
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550
Mailing Address - Country:US
Mailing Address - Phone:914-363-3204
Mailing Address - Fax:
Practice Address - Street 1:54 S 2ND AVE
Practice Address - Street 2:APT B-4
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-3438
Practice Address - Country:US
Practice Address - Phone:914-363-3204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294975164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse