Provider Demographics
NPI:1104263524
Name:GRAY, MELISSA C (LPN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:C
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 1:4839 REDMAN RD
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-9612
Mailing Address - Country:US
Mailing Address - Phone:585-330-0843
Mailing Address - Fax:
Practice Address - Street 1:4839 REDMAN RD
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-9612
Practice Address - Country:US
Practice Address - Phone:585-330-0843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300698164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse