Provider Demographics
NPI:1275099061
Name:GRAVELL, TANYA NICOLE (CNM)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:NICOLE
Last Name:GRAVELL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 748860
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8858
Mailing Address - Country:US
Mailing Address - Phone:602-240-2401
Mailing Address - Fax:602-792-0244
Practice Address - Street 1:650 W MARYLAND AVE STE 1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-1399
Practice Address - Country:US
Practice Address - Phone:602-240-2401
Practice Address - Fax:602-792-0244
Is Sole Proprietor?:No
Enumeration Date:2019-02-16
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ176B00000X
AZ225524367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife