Provider Demographics
NPI:1497862379
Name:GRIGAITIS-REYES, MICHELE M (NP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:M
Last Name:GRIGAITIS-REYES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E WILLETTA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2727
Mailing Address - Country:US
Mailing Address - Phone:602-839-3097
Mailing Address - Fax:602-839-6906
Practice Address - Street 1:2910 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4434
Practice Address - Country:US
Practice Address - Phone:602-406-4856
Practice Address - Fax:602-406-3369
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2077363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ916603Medicaid
AZ916603Medicaid
AZ101682Medicare ID - Type UnspecifiedMEDICARE #