Provider Demographics
NPI:1215531405
Name:ZANCO-GRAYSON, MARY (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ZANCO-GRAYSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 MADISON BLVD # D102-141
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-2031
Mailing Address - Country:US
Mailing Address - Phone:256-258-8412
Mailing Address - Fax:
Practice Address - Street 1:8000 MADISON BLVD # D102-141
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2031
Practice Address - Country:US
Practice Address - Phone:256-258-8412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-28
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR103620163W00000X
AL1-197836363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse