Provider Demographics
NPI:1215445622
Name:GRAY, COURTNEY ROSE (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ROSE
Last Name:GRAY
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:ROSE
Other - Last Name:POTTGEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:1625 SHADOW OAK DR
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-3376
Mailing Address - Country:US
Mailing Address - Phone:314-401-0111
Mailing Address - Fax:
Practice Address - Street 1:1390 US HIGHWAY 61 STE N1500
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028
Practice Address - Country:US
Practice Address - Phone:636-933-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017040265363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health