Basic Information
| Provider Information | |||||||||
| NPI: | 1063526366 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | LUCY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAY | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | LUCY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4913 W RENO AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731276339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059484900 | ||||||||
| FaxNumber: | 4055953197 | ||||||||
| Practice Location | |||||||||
| Address1: | 4913 W RENO AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731276339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059484900 | ||||||||
| FaxNumber: | 4055953197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 06/27/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | R0070730 | OK | N | Nursing Service Providers | Registered Nurse | Community Health | 163WD0400X | R0070730 | OK | N | Nursing Service Providers | Registered Nurse | Diabetes Educator | 163WC0400X | R0070730 | OK | Y | Nursing Service Providers | Registered Nurse | Case Management |
No ID Information.