Provider Demographics
NPI:1669058723
Name:GRAY, JANET
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MS
Mailing Address - Zip Code:39041-0005
Mailing Address - Country:US
Mailing Address - Phone:769-798-6554
Mailing Address - Fax:
Practice Address - Street 1:159 JOHN DAVIS DR
Practice Address - Street 2:
Practice Address - City:BOLTON
Practice Address - State:MS
Practice Address - Zip Code:39041-3202
Practice Address - Country:US
Practice Address - Phone:769-798-6554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1245285374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide