Provider Demographics
NPI:1063094787
Name:GRAY, KATLYN ELIZABETH
Entity type:Individual
Prefix:
First Name:KATLYN
Middle Name:ELIZABETH
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 1:248 RED OAKS SHOPPING CTR
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-1349
Mailing Address - Country:US
Mailing Address - Phone:304-645-6226
Mailing Address - Fax:
Practice Address - Street 1:POCAHONTAS STREET WEST
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:WV
Practice Address - Zip Code:25984
Practice Address - Country:US
Practice Address - Phone:304-992-4586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3747P1801XOtherNPI