Provider Demographics
NPI:1689002230
Name:GRAY, IESHA (LPN)
Entity Type:Individual
Prefix:
First Name:IESHA
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 1:123 E PATH RISE
Mailing Address - Street 2:
Mailing Address - City:WEST HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14586-8601
Mailing Address - Country:US
Mailing Address - Phone:585-469-6921
Mailing Address - Fax:
Practice Address - Street 1:123 E PATH RISE
Practice Address - Street 2:
Practice Address - City:WEST HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14586-8601
Practice Address - Country:US
Practice Address - Phone:585-469-6921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY316650164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse