Provider Demographics
NPI:1922825769
Name:BOVA GRAY, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:BOVA 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 1:1236 CRANE MEADOW WAY
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-9010
Mailing Address - Country:US
Mailing Address - Phone:414-841-5109
Mailing Address - Fax:
Practice Address - Street 1:1315 MARION AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-3007
Practice Address - Country:US
Practice Address - Phone:414-795-1710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100229226Medicaid