Provider Demographics
NPI:1679117394
Name:GRAY, MARY A
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
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 1:613 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-1520
Mailing Address - Country:US
Mailing Address - Phone:662-837-7178
Mailing Address - Fax:
Practice Address - Street 1:613 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-1520
Practice Address - Country:US
Practice Address - Phone:662-837-7178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider