Provider Demographics
NPI:1902520307
Name:PITTARI, GRACEANN ASHLEY
Entity Type:Individual
Prefix:
First Name:GRACEANN
Middle Name:ASHLEY
Last Name:PITTARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4216 W COLTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-8925
Mailing Address - Country:US
Mailing Address - Phone:845-820-7685
Mailing Address - Fax:
Practice Address - Street 1:14221 E 4TH AVE BLDG 2-126
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-8735
Practice Address - Country:US
Practice Address - Phone:720-507-4779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVTEMP859121363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health