Provider Demographics
NPI:1770186538
Name:GRAY, SHANNON (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10097
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85130-0020
Mailing Address - Country:US
Mailing Address - Phone:520-836-3446
Mailing Address - Fax:
Practice Address - Street 1:174 W HIGHWAY 287
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132
Practice Address - Country:US
Practice Address - Phone:520-868-5811
Practice Address - Fax:520-868-1223
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ242590363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily