Basic Information
| Provider Information | |||||||||
| NPI: | 1891052460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAY-WALKER | ||||||||
| FirstName: | SUZETTE | ||||||||
| MiddleName: | ANNMARIE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 S. PINE ISLAND ROAD | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052458050 | ||||||||
| FaxNumber: | 3052455950 | ||||||||
| Practice Location | |||||||||
| Address1: | 9611 W BROWARD BLVD | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333242334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544247000 | ||||||||
| FaxNumber: | 9544246003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2012 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | APRN1968432 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 008453100 | 05 | FL | MEDICAID |