Provider Demographics
NPI:1780397646
Name:GRAY, MAHALA (APRN, CNP)
Entity type:Individual
Prefix:
First Name:MAHALA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 ELM HILL PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37214-3108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1095 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-3840
Practice Address - Country:US
Practice Address - Phone:937-528-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.443268163W00000X
OHAPRN.CNP.0032481363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPRN.CNP.0032481OtherOHIO BOARD OF NURSING
OHRN.443268OtherOHIO BOARD OF NURSING
OHF07220675OtherAANP