Provider Demographics
NPI:1801559984
Name:GRAVELINE, LISA MAE DIANE (PMHNP-BC, APRN-RNP)
Entity type:Individual
Prefix:
First Name:LISA MAE
Middle Name:DIANE
Last Name:GRAVELINE
Suffix:
Gender:F
Credentials:PMHNP-BC, APRN-RNP
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Mailing Address - Street 1:3274 BOB DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-8640
Mailing Address - Country:US
Mailing Address - Phone:928-203-5414
Mailing Address - Fax:866-984-3891
Practice Address - Street 1:3274 BOB DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-8640
Practice Address - Country:US
Practice Address - Phone:928-203-5414
Practice Address - Fax:866-984-3891
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZRNP265685363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZRNP-265685OtherSTATE LICENSE NUMBER