Provider Demographics
NPI:1750663696
Name:GRAY, ROXY DOVE (RN)
Entity type:Individual
Prefix:MRS
First Name:ROXY
Middle Name:DOVE
Last Name:GRAY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 IVORY ST
Mailing Address - Street 2:
Mailing Address - City:FREWSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14738-9531
Mailing Address - Country:US
Mailing Address - Phone:716-569-7083
Mailing Address - Fax:716-569-7006
Practice Address - Street 1:135 IVORY ST
Practice Address - Street 2:
Practice Address - City:FREWSBURG
Practice Address - State:NY
Practice Address - Zip Code:14738-9531
Practice Address - Country:US
Practice Address - Phone:716-569-7083
Practice Address - Fax:716-569-7006
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258683-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY163W00000XMedicaid