Provider Demographics
NPI:1265165229
Name:GRAY, KIMBERLY (PMHNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2382 E WINDING BROOK CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4382
Mailing Address - Country:US
Mailing Address - Phone:812-327-2810
Mailing Address - Fax:
Practice Address - Street 1:65 AIRPORT PKWY
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1439
Practice Address - Country:US
Practice Address - Phone:317-887-1348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28212858A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health