Provider Demographics
NPI:1821183831
Name:GRAY, PENNIE MARIE (CNS)
Entity Type:Individual
Prefix:
First Name:PENNIE
Middle Name:MARIE
Last Name:GRAY
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18660 EAST BAGLEY ROAD
Mailing Address - Street 2:SUITE 405 PHASE II
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-8492
Mailing Address - Country:US
Mailing Address - Phone:440-243-0530
Mailing Address - Fax:440-243-3351
Practice Address - Street 1:18660 EAST BAGLEY ROAD
Practice Address - Street 2:SUITE 405 PHASE II
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-8492
Practice Address - Country:US
Practice Address - Phone:440-243-0530
Practice Address - Fax:440-243-3351
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN187429163WP0809X
OHNS02451364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Not Answered364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGRNS02601Medicare ID - Type Unspecified
Q02839Medicare UPIN