Healthcare Provider Details

I. General information

NPI: 1669179784
Provider Name (Legal Business Name): ARIELLE JACQUELYN MARION GRANVOLD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 02/09/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11101 US HIGHWAY 380 CLINIC #10138
CROSSROADS TX
76227-8203
US

IV. Provider business mailing address

11101 US HIGHWAY 380 CLINIC #10138
CROSSROADS TX
76227-8203
US

V. Phone/Fax

Practice location:
  • Phone: 940-365-5762
  • Fax:
Mailing address:
  • Phone: 940-365-5762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1109840
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: