Basic Information
| Provider Information | |||||||||
| NPI: | 1790001469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | LINDSEY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4600 FORT HENRY DR | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376632617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243950 | ||||||||
| FaxNumber: | 4232243959 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 FORT HENRY DR | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376632617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243950 | ||||||||
| FaxNumber: | 4232243959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2010 | ||||||||
| LastUpdateDate: | 04/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 14927 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 0024169595 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1520644 | 05 | TN | MEDICAID | 1790001469 | 05 | VA | MEDICAID |