Basic Information
| Provider Information | |||||||||
| NPI: | 1649870486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | LORRAINE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6680 POE AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454142855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372808400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3120 GOVERNORS PLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454091328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372931622 | ||||||||
| FaxNumber: | 9372456308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2020 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.0027943 | OH | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | APRN.CNP.0027943 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0424845 | 05 | OH | MEDICAID |