Healthcare Provider Details

I. General information

NPI: 1710042957
Provider Name (Legal Business Name): JANET MICHELLE GRADLE CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 S IDAHO RD SUITE 206
APACHE JUNCTION AZ
85219-6496
US

IV. Provider business mailing address

2502 N CABOT
MESA AZ
85207-1516
US

V. Phone/Fax

Practice location:
  • Phone: 480-889-1234
  • Fax:
Mailing address:
  • Phone: 480-889-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPO241
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: