Healthcare Provider Details

I. General information

NPI: 1689063323
Provider Name (Legal Business Name): JAREN P GRAVAGNE CNP, RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2015
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LANG AVE NE
ALBUQUERQUE NM
87109-4397
US

IV. Provider business mailing address

610 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2372
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-8171
  • Fax: 505-246-0684
Mailing address:
  • Phone: 505-242-3991
  • Fax: 505-242-3993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR57758
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberR57758
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02956
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-02956
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: