Provider Demographics
NPI:1790130029
Name:REDD-GRAY, MARJORIE L (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:L
Last Name:REDD-GRAY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1339 SUNNY GLEN DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75232-1121
Mailing Address - Country:US
Mailing Address - Phone:469-449-3143
Mailing Address - Fax:
Practice Address - Street 1:BROOKE ARMY MEDICAL CENTER
Practice Address - Street 2:3551 ROGER BROOKE DR
Practice Address - City:JBSA FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-539-9271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-23
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0416302363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily