Provider Demographics
NPI:1306070701
Name:GRAY, SUSAN WAMBUI
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:WAMBUI
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14055 BUDWORTH CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-6123
Mailing Address - Country:US
Mailing Address - Phone:770-912-8905
Mailing Address - Fax:
Practice Address - Street 1:14055 BUDWORTH CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-6123
Practice Address - Country:US
Practice Address - Phone:770-912-8905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN074267164W00000X
FL11016895363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse