Provider Demographics
NPI:1750879649
Name:GRAYSON, HEATHER (AGNP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 SOUTHEAST PKWY
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-3658
Mailing Address - Country:US
Mailing Address - Phone:817-661-8197
Mailing Address - Fax:888-227-6422
Practice Address - Street 1:807 SOUTHEAST PKWY
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-3658
Practice Address - Country:US
Practice Address - Phone:817-661-8197
Practice Address - Fax:888-227-6422
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137382363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology