Provider Demographics
NPI:1184738734
Name:GRAY, BENNIE B (ARNP)
Entity type:Individual
Prefix:
First Name:BENNIE
Middle Name:B
Last Name:GRAY
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8338 W 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-2900
Mailing Address - Country:US
Mailing Address - Phone:316-729-1030
Mailing Address - Fax:
Practice Address - Street 1:8338 W 13TH ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-2900
Practice Address - Country:US
Practice Address - Phone:316-729-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-36340-111163W00000X
KS44008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00266942OtherRR MEDICARE
R84426Medicare UPIN
KS161525Medicare ID - Type Unspecified