Provider Demographics
NPI:1710704580
Name:GRAY, DIAN SUDENE (FNP)
Entity type:Individual
Prefix:MRS
First Name:DIAN
Middle Name:SUDENE
Last Name:GRAY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 HILLTOP DR
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:FL
Mailing Address - Zip Code:33838-4442
Mailing Address - Country:US
Mailing Address - Phone:609-582-3413
Mailing Address - Fax:
Practice Address - Street 1:1709 HILLTOP DR
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:FL
Practice Address - Zip Code:33838-4442
Practice Address - Country:US
Practice Address - Phone:609-582-3413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11035448363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner