Provider Demographics
NPI:1619633989
Name:GRAY, KIMBERLY MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:GRAY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3235 HARVEST CRST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:TX
Mailing Address - Zip Code:78124-1407
Mailing Address - Country:US
Mailing Address - Phone:210-439-9450
Mailing Address - Fax:
Practice Address - Street 1:12315 JUDSON RD STE 110
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3263
Practice Address - Country:US
Practice Address - Phone:210-566-8332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1046983363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner