Provider Demographics
NPI:1912718974
Name:GRAY, SARA (ICP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:ICP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 GLENNA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-2719
Mailing Address - Country:US
Mailing Address - Phone:513-907-8880
Mailing Address - Fax:
Practice Address - Street 1:6649 CREEKSIDE WAY
Practice Address - Street 2:
Practice Address - City:FAIRFIELD TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45011-7939
Practice Address - Country:US
Practice Address - Phone:901-417-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172A00000XOther Service ProvidersDriver