Provider Demographics
NPI:1699965772
Name:GRAY, SHARON S (RD)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:S
Last Name:GRAY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:65 KANE ST
Practice Address - Street 2:GENETICS
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-2110
Practice Address - Country:US
Practice Address - Phone:860-523-6464
Practice Address - Fax:860-523-6465
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT000771133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT710000212Medicare PIN