Provider Demographics
NPI:1770616559
Name:GRAY, SUSAN KAY (FNP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KAY
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:PO BOX 77
Mailing Address - Street 2:109 N CHESTNUT
Mailing Address - City:ONARGA
Mailing Address - State:IL
Mailing Address - Zip Code:60955
Mailing Address - Country:US
Mailing Address - Phone:815-268-4840
Mailing Address - Fax:815-268-4845
Practice Address - Street 1:109 N CHESTNUT
Practice Address - Street 2:
Practice Address - City:ONARGA
Practice Address - State:IL
Practice Address - Zip Code:60955
Practice Address - Country:US
Practice Address - Phone:815-268-4840
Practice Address - Fax:815-268-4845
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL41-207013363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ57637Medicare UPIN
IL143425Medicare PIN