Healthcare Provider Details

I. General information

NPI: 1821028820
Provider Name (Legal Business Name): LISA MARIE GRAVELLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA M. GRAVELLE M.D.

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5063 S COTTONWOOD ST
SALT LAKE CITY UT
84107-6766
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-1800
  • Fax: 801-507-1825
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5640031-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: