Provider Demographics
NPI:1649279639
Name:GRAY, JODY A (WHNP)
Entity type:Individual
Prefix:MRS
First Name:JODY
Middle Name:A
Last Name:GRAY
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 BLUE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:STOUT
Mailing Address - State:OH
Mailing Address - Zip Code:45684-9627
Mailing Address - Country:US
Mailing Address - Phone:934-544-9391
Mailing Address - Fax:
Practice Address - Street 1:1729 27TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2638
Practice Address - Country:US
Practice Address - Phone:740-354-1434
Practice Address - Fax:740-353-8811
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP03617363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health