Provider Demographics
NPI:1821388034
Name:WILLIS-GRAY, MARCELLA GEVONNE
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:GEVONNE
Last Name:WILLIS-GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARCELLA
Other - Middle Name:GEVONNE
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4325 LAKE BOONE TRL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7509
Mailing Address - Country:US
Mailing Address - Phone:984-974-0498
Mailing Address - Fax:984-974-0497
Practice Address - Street 1:3032 OLD CLINIC BLDG
Practice Address - Street 2:CB#7570
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-7570
Practice Address - Country:US
Practice Address - Phone:919-966-4717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-10
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-002562088F0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088F0040XAllopathic & Osteopathic PhysiciansUrologyFemale Pelvic Medicine and Reconstructive Surgery