Provider Demographics
NPI:1386376390
Name:GRAY, LISA DARLENE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DARLENE
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 1:1511 HIGHWAY 25B
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-1701
Mailing Address - Country:US
Mailing Address - Phone:501-362-9426
Mailing Address - Fax:501-362-9456
Practice Address - Street 1:1511 HIGHWAY 25B
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-1701
Practice Address - Country:US
Practice Address - Phone:501-362-9426
Practice Address - Fax:501-362-9456
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL49989164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse