Provider Demographics
NPI:1386248375
Name:GRAY, ANGELA NECHELLE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:NECHELLE
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 1:109 WESTROCK FARM DR
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-2945
Mailing Address - Country:US
Mailing Address - Phone:937-751-2566
Mailing Address - Fax:
Practice Address - Street 1:109 WESTROCK FARM DR
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2945
Practice Address - Country:US
Practice Address - Phone:937-751-2566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRV332116253Z00000X, 347C00000X, 376J00000X, 385HR2060X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
No376J00000XNursing Service Related ProvidersHomemaker
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child