Provider Demographics
NPI:1285239434
Name:BLAGRAVE, JULIETA MONTINA
Entity type:Individual
Prefix:
First Name:JULIETA
Middle Name:MONTINA
Last Name:BLAGRAVE
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 1:2095 CROSSWOODS CIR
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-8860
Mailing Address - Country:US
Mailing Address - Phone:360-675-5058
Mailing Address - Fax:
Practice Address - Street 1:2095 CROSSWOODS CIR
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-8860
Practice Address - Country:US
Practice Address - Phone:360-675-5058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3747A0650X-TECHNICIAMedicaid