Basic Information
| Provider Information | |||||||||
| NPI: | 1689063323 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAVAGNE | ||||||||
| FirstName: | JAREN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CNP, RNFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 BROADWAY BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052423991 | ||||||||
| FaxNumber: | 5052423993 | ||||||||
| Practice Location | |||||||||
| Address1: | 4901 LANG AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058428171 | ||||||||
| FaxNumber: | 5052460684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2015 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R57758 | NM | N | Nursing Service Providers | Registered Nurse | 163WR0006X | R57758 | NM | N | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant | 363LF0000X | CNP-02956 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | CNP-02956 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | R57758 | 01 | NM | RN LICENSE | OTHER | CNP-02956 | 01 | NM | CERTIFIED NURSE PRACTIONER LICENSE | OTHER |