| NPI | 1154361640 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRENDA DE GRAY Credentialing 800-370-3651 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner |
| Additional Taxonomies | 207RG0300X Internal Medicine, Geriatric Medicine |
| Enumeration Date | 2006-06-07 |
| Last Update Date | 2009-03-11 |