Provider Demographics
NPI:1689063323
Name:GRAVAGNE, JAREN P (CNP, RNFA)
Entity Type:Individual
Prefix:MRS
First Name:JAREN
Middle Name:P
Last Name:GRAVAGNE
Suffix:
Gender:F
Credentials:CNP, RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 BROADWAY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2372
Mailing Address - Country:US
Mailing Address - Phone:505-242-3991
Mailing Address - Fax:505-242-3993
Practice Address - Street 1:4901 LANG AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4397
Practice Address - Country:US
Practice Address - Phone:505-842-8171
Practice Address - Fax:505-246-0684
Is Sole Proprietor?:No
Enumeration Date:2015-01-19
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR57758163W00000X, 163WR0006X
NMCNP-02956363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR57758OtherRN LICENSE
NMCNP-02956OtherCERTIFIED NURSE PRACTIONER LICENSE