1801559984 NPI number — LISA MAE DIANE GRAVELINE PMHNP-BC, APRN-RNP

Table of content: LISA MAE DIANE GRAVELINE PMHNP-BC, APRN-RNP (NPI 1801559984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801559984 NPI number — LISA MAE DIANE GRAVELINE PMHNP-BC, APRN-RNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAVELINE
Provider First Name:
LISA MAE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-BC, APRN-RNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801559984
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3274 BOB DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESCOTT VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86314-8640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-203-5414
Provider Business Mailing Address Fax Number:
866-984-3891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3274 BOB DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86314-8640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-203-5414
Provider Business Practice Location Address Fax Number:
866-984-3891
Provider Enumeration Date:
10/15/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  RNP265685 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RNP-265685 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com