Provider Demographics
NPI:1881295459
Name:GRAY, MARIETTE ZANDERS (APRN)
Entity type:Individual
Prefix:
First Name:MARIETTE
Middle Name:ZANDERS
Last Name:GRAY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473 ELK CLUB RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32352-6492
Mailing Address - Country:US
Mailing Address - Phone:850-856-9426
Mailing Address - Fax:
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHATTAHOOCHEE
Practice Address - State:FL
Practice Address - Zip Code:32324-1107
Practice Address - Country:US
Practice Address - Phone:850-663-7383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11009858363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health