Provider Demographics
NPI:1851685135
Name:GRAYSON, DEANNE ELIZABETH (DO)
Entity Type:Individual
Prefix:DR
First Name:DEANNE
Middle Name:ELIZABETH
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 PLANTATION ISLAND DR S STE 110
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5173
Mailing Address - Country:US
Mailing Address - Phone:904-824-7733
Mailing Address - Fax:
Practice Address - Street 1:1100 PLANTATION ISLAND DR S
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-5173
Practice Address - Country:US
Practice Address - Phone:904-824-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-05
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-15342084P0800X, 208D00000X
FLOS162872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN