Provider Demographics
NPI:1053739276
Name:GRAY, CRYSTAL J (LPN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:J
Last Name:GRAY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3427 W VILLARD AVE
Mailing Address - Street 2:APT 307
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4700
Mailing Address - Country:US
Mailing Address - Phone:414-388-5340
Mailing Address - Fax:
Practice Address - Street 1:3427 W VILLARD AVE
Practice Address - Street 2:APT 307
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-4700
Practice Address - Country:US
Practice Address - Phone:414-388-5340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32603-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse