Provider Demographics
NPI:1699409771
Name:GRAY, SHANNON MARKETA (RN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARKETA
Last Name:GRAY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 WALNUT PARK DR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4159
Mailing Address - Country:US
Mailing Address - Phone:757-725-1018
Mailing Address - Fax:
Practice Address - Street 1:819 WALNUT PARK DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4159
Practice Address - Country:US
Practice Address - Phone:757-725-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001294835163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator