Provider Demographics
NPI:1699738153
Name:DEGRAZIO, BRENDA MARIE (CNM)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:MARIE
Last Name:DEGRAZIO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MRS
Other - First Name:BRENDA
Other - Middle Name:MARIE
Other - Last Name:ALLINGTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:STE 217
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-728-8170
Mailing Address - Fax:406-728-9409
Practice Address - Street 1:2825 FORT MISSOULA RD
Practice Address - Street 2:STE 217
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7403
Practice Address - Country:US
Practice Address - Phone:406-728-8170
Practice Address - Fax:406-728-9409
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRH019408367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0433771Medicaid
81036208059804A005OtherTRICARE
MT000036190OtherBCBS
000080071Medicare ID - Type Unspecified