Provider Demographics
NPI:1649779612
Name:GRAY, BOBBY (LPN)
Entity Type:Individual
Prefix:MS
First Name:BOBBY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 DICK RD APT A3
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-1840
Mailing Address - Country:US
Mailing Address - Phone:716-573-1224
Mailing Address - Fax:
Practice Address - Street 1:474 DICK RD, APT A3
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-1404
Practice Address - Country:US
Practice Address - Phone:716-573-1224
Practice Address - Fax:716-573-1224
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY327456164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse