Provider Demographics
NPI:1215338496
Name:GRAY, BETHANY (LPN)
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:
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 1:508 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-5420
Mailing Address - Country:US
Mailing Address - Phone:315-271-9698
Mailing Address - Fax:
Practice Address - Street 1:508 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-5420
Practice Address - Country:US
Practice Address - Phone:315-271-9698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10 316354164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse