Provider Demographics
NPI:1831759547
Name:GRAY, TRACI TAYLOR (AGNP-C)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:TAYLOR
Last Name:GRAY
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 N BOLTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-4407
Mailing Address - Country:US
Mailing Address - Phone:318-693-1311
Mailing Address - Fax:318-693-1313
Practice Address - Street 1:2200 N BOLTON AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-4407
Practice Address - Country:US
Practice Address - Phone:318-639-1311
Practice Address - Fax:318-693-1313
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206362363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care