Provider Demographics
NPI:1154629178
Name:GRAY, ASHLEY D (FNP)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:D
Last Name:GRAY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83A OLD MILL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:MS
Mailing Address - Zip Code:39330-9649
Mailing Address - Country:US
Mailing Address - Phone:601-704-1020
Mailing Address - Fax:601-704-1021
Practice Address - Street 1:83A OLD MILL CREEK RD
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:MS
Practice Address - Zip Code:39330-9649
Practice Address - Country:US
Practice Address - Phone:601-704-1020
Practice Address - Fax:601-704-1021
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR876926363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09337094Medicaid
MS302I500632Medicare PIN