Healthcare Provider Details

I. General information

NPI: 1275099061
Provider Name (Legal Business Name): TANYA NICOLE GRAVELL CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2019
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W MARYLAND AVE STE 1
PHOENIX AZ
85013-1399
US

IV. Provider business mailing address

PO BOX 748860
ATLANTA GA
30374-8858
US

V. Phone/Fax

Practice location:
  • Phone: 602-240-2401
  • Fax: 602-792-0244
Mailing address:
  • Phone: 602-240-2401
  • Fax: 602-792-0244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number225524
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: