Basic Information
Provider Information | |||||||||
NPI: | 1508430893 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAY | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | ARMACOST | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | AGACNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BREWINGTON | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | ARMACOST | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 755 WALTHER RD | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300468725 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709624895 | ||||||||
FaxNumber: | 6783773816 | ||||||||
Practice Location | |||||||||
Address1: | 755 WALTHER RD | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300468725 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709624895 | ||||||||
FaxNumber: | 6783773816 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2021 | ||||||||
LastUpdateDate: | 07/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 248100 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 363L00000X | RN248100 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.