Provider Demographics
NPI:1023485182
Name:GRAY, ELISE (CNP)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:CNP
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Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DRIVE
Mailing Address - Street 2:SUITE J2000
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:5333 MCAULEY DR
Practice Address - Street 2:SUITE 6109
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-712-1400
Practice Address - Fax:734-623-2857
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2024-11-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OHCOA-17818-NP363L00000X
MI4704389046363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0142537Medicaid