Provider Demographics
NPI:1457731408
Name:GRAY, NICOLE ANJOU O'BLENESS (CNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANJOU O'BLENESS
Last Name:GRAY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANJOU
Other - Last Name:O'BLENESS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNP
Mailing Address - Street 1:395 W 12TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1267
Mailing Address - Country:US
Mailing Address - Phone:614-293-6255
Mailing Address - Fax:614-293-6265
Practice Address - Street 1:410 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-6255
Practice Address - Fax:614-293-6265
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.17402-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health