Provider Demographics
NPI:1649620865
Name:GRAY, NATASHA B (FNP)
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:B
Last Name:GRAY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2238 N 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-2603
Mailing Address - Country:US
Mailing Address - Phone:708-717-0043
Mailing Address - Fax:
Practice Address - Street 1:1200 N LARRABEE ST
Practice Address - Street 2:MINUTECLINIC
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-1746
Practice Address - Country:US
Practice Address - Phone:708-717-0043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-18
Last Update Date:2016-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014082363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily