Provider Demographics
NPI:1134827926
Name:GRAY, TARA CORNELLA (APRN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:CORNELLA
Last Name:GRAY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 SARVIS BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6354
Mailing Address - Country:US
Mailing Address - Phone:606-813-3171
Mailing Address - Fax:
Practice Address - Street 1:740 E LAUREL RD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-8601
Practice Address - Country:US
Practice Address - Phone:606-877-3950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3019042363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily