1124370010 NPI number — SAMANTHA M GRAY FNP

Table of content: SAMANTHA M GRAY FNP (NPI 1124370010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124370010 NPI number — SAMANTHA M GRAY FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
SAMANTHA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124370010
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 SILVERSIDE RD
Provider Second Line Business Mailing Address:
SUITE 111
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19809-1774
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-798-0666
Provider Business Mailing Address Fax Number:
302-798-2401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 GLASGOW AVE
Provider Second Line Business Practice Location Address:
SUITE 124
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19702-4773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-836-4200
Provider Business Practice Location Address Fax Number:
302-836-8431
Provider Enumeration Date:
10/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  LG-0000634 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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