Basic Information
| Provider Information | |||||||||
| NPI: | 1336368307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | ROACH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4050 RUTLEDGE PIKE | ||||||||
| Address2: | |||||||||
| City: | BLAINE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377095006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8658285092 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6350 WEST ANDREW JOHNSON HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | TALBOTT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237142200 | ||||||||
| FaxNumber: | 4235860614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 0000012667 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 1521656 | 05 | TN | MEDICAID |