Healthcare Provider Details

I. General information

NPI: 1770383101
Provider Name (Legal Business Name): GARYN GRIJALVA FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2025
Last Update Date: 03/14/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1895 N JASPER DR STE 1
FLAGSTAFF AZ
86001-1632
US

IV. Provider business mailing address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-2332
  • Fax:
Mailing address:
  • Phone: 928-779-3366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number320120
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number320120
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: