Provider Demographics
NPI:1902446503
Name:GRAY, LAURA (FNP-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:D
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4235
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86302-4235
Mailing Address - Country:US
Mailing Address - Phone:928-460-9866
Mailing Address - Fax:928-259-2885
Practice Address - Street 1:1000 WILLOW CREEK RD STE A
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1645
Practice Address - Country:US
Practice Address - Phone:928-460-9866
Practice Address - Fax:928-259-2885
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ236320363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner