Provider Demographics
NPI:1811398084
Name:MICHAUD-GRAY, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MICHAUD-GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-3450
Mailing Address - Country:US
Mailing Address - Phone:603-743-4885
Mailing Address - Fax:
Practice Address - Street 1:595 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-3450
Practice Address - Country:US
Practice Address - Phone:603-743-4885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH064884-21163W00000X
MARN2289864163W00000X
NH0461M174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No163W00000XNursing Service ProvidersRegistered Nurse