Provider Demographics
NPI:1144801143
Name:GRAY, CHARLES LEE JR (FNP-BC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:GRAY
Suffix:JR
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 FIRE STATION RD
Mailing Address - Street 2:
Mailing Address - City:BAILEYTON
Mailing Address - State:AL
Mailing Address - Zip Code:35019-9609
Mailing Address - Country:US
Mailing Address - Phone:256-735-4057
Mailing Address - Fax:
Practice Address - Street 1:105 FIRE STATION RD
Practice Address - Street 2:
Practice Address - City:BAILEYTON
Practice Address - State:AL
Practice Address - Zip Code:35019-9609
Practice Address - Country:US
Practice Address - Phone:256-735-4057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-102412363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty