Healthcare Provider Details

I. General information

NPI: 1164960720
Provider Name (Legal Business Name): GRAVIL JOSEPH APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10515 SW 24TH ST
MIRAMAR FL
33025-3996
US

IV. Provider business mailing address

10515 SW 24TH ST
MIRAMAR FL
33025-3996
US

V. Phone/Fax

Practice location:
  • Phone: 305-767-0887
  • Fax:
Mailing address:
  • Phone: 305-767-0887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberAP60792299
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberAP11258
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number9359865
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9359865
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: