Provider Demographics
NPI:1447028220
Name:GRAY, SHANELL VONTRES
Entity type:Individual
Prefix:
First Name:SHANELL
Middle Name:VONTRES
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 ST GEORGES CIR
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:33839-5211
Mailing Address - Country:US
Mailing Address - Phone:863-535-8954
Mailing Address - Fax:
Practice Address - Street 1:237 ST GEORGES CIR
Practice Address - Street 2:
Practice Address - City:EAGLE LAKE
Practice Address - State:FL
Practice Address - Zip Code:33839-5211
Practice Address - Country:US
Practice Address - Phone:863-535-8954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker