Provider Demographics
NPI:1306499264
Name:GRAY, DOMINIQUEKAL BROWN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:DOMINIQUEKAL
Middle Name:BROWN
Last Name:GRAY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8032C LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-3239
Mailing Address - Country:US
Mailing Address - Phone:301-846-0090
Mailing Address - Fax:
Practice Address - Street 1:8032C LIBERTY RD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-3239
Practice Address - Country:US
Practice Address - Phone:301-846-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903216363LF0000X
MDAC003096363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily