Provider Demographics
NPI:1336368307
Name:GRAY, JULIE ROACH (NP)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ROACH
Last Name:GRAY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 RUTLEDGE PIKE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:TN
Mailing Address - Zip Code:37709-5006
Mailing Address - Country:US
Mailing Address - Phone:865-828-5092
Mailing Address - Fax:
Practice Address - Street 1:6350 WEST ANDREW JOHNSON HIGHWAY
Practice Address - Street 2:
Practice Address - City:TALBOTT
Practice Address - State:TN
Practice Address - Zip Code:37877
Practice Address - Country:US
Practice Address - Phone:423-714-2200
Practice Address - Fax:423-586-0614
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000012667363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1521656Medicaid