Provider Demographics
NPI:1851901052
Name:GRAGG, ANGELA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:GRAGG
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 W GUADALUPE RD APT 205
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-9113
Mailing Address - Country:US
Mailing Address - Phone:205-365-3724
Mailing Address - Fax:
Practice Address - Street 1:1325 W GUADALUPE RD APT 205
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-9113
Practice Address - Country:US
Practice Address - Phone:205-356-3724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN210629163WA0400X, 163WC1500X, 163WC1600X, 163WH1000X, 163WW0000X, 163WN1003X
VI11647163WG0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support