Provider Demographics
NPI:1992826291
Name:GRAY, JUDITH LYNN (MSN)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:LYNN
Last Name:GRAY
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 DE SOTO ST
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-2055
Mailing Address - Country:US
Mailing Address - Phone:202-877-1000
Mailing Address - Fax:
Practice Address - Street 1:5500 DE SOTO ST
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-2055
Practice Address - Country:US
Practice Address - Phone:202-877-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN62406363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC005808M53Medicare PIN
P14238Medicare UPIN