Healthcare Provider Details

I. General information

NPI: 1952240962
Provider Name (Legal Business Name): ANGELINA RENEE GRADILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15818 N 25TH ST UNIT 124
PHOENIX AZ
85032-3598
US

IV. Provider business mailing address

15818 N 25TH ST UNIT 124
PHOENIX AZ
85032-3598
US

V. Phone/Fax

Practice location:
  • Phone: 812-614-7679
  • Fax:
Mailing address:
  • Phone: 812-614-7679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-3077
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: