Provider Demographics
NPI:1912690652
Name:GRAY, MISTY
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2461
Mailing Address - Country:US
Mailing Address - Phone:262-970-6653
Mailing Address - Fax:262-896-8180
Practice Address - Street 1:1501 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2461
Practice Address - Country:US
Practice Address - Phone:262-970-6653
Practice Address - Fax:262-896-8180
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI252751163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health