Provider Demographics
NPI:1952091217
Name:GRAY, ANTONETTE PATRICE
Entity Type:Individual
Prefix:
First Name:ANTONETTE
Middle Name:PATRICE
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:PO BOX 65996
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84165-0996
Mailing Address - Country:US
Mailing Address - Phone:801-781-9183
Mailing Address - Fax:
Practice Address - Street 1:3990 S HOWICK ST UNIT A111
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84107-3202
Practice Address - Country:US
Practice Address - Phone:801-781-9183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2023PCAUT001039374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide