MEDICARE: ANGELA GRAGG REGISTERED NURSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WA0400X	Addiction (Substance Use Disorder) Registered Nurse	RN210629	AZ
2	163WC1500X	Community Health Registered Nurse	RN210629	AZ
3	163WC1600X	Continuing Education/Staff Development Registered Nurse	RN210629	AZ
4	163WG0000X	General Practice Registered Nurse	11647	VI
5	163WH1000X	Hospice Registered Nurse	RN210629	AZ
6	163WW0000X	Wound Care Registered Nurse	RN210629	AZ
7	163W00000X	Registered Nurse	11647	VI
8	163WN1003X	Nutrition Support Registered Nurse	RN210629	AZ

General Provider Information

NPI Number	:	1851901052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA GRAGG REGISTERED NURSE

Provider Business Mailing Address
First Line	:	1325 W GUADALUPE RD APT 205
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85202-9113
Country	:	US
Telephone Number	:	205-365-3724
Fax Number	:

Provider Business Practice Location Address
First Line	:	1325 W GUADALUPE RD APT 205
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85202-9113
Country	:	US
Telephone Number	:	205-356-3724
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2020
Last Update Date	:	08/03/2020

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