Provider Demographics
NPI:1851490726
Name:RIVENBARK, JULIE E
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:E
Last Name:RIVENBARK
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 1:10 CROSSROADS DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5458
Mailing Address - Country:US
Mailing Address - Phone:410-484-8088
Mailing Address - Fax:410-581-9485
Practice Address - Street 1:10 CROSSROADS DR
Practice Address - Street 2:SUITE 210
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5458
Practice Address - Country:US
Practice Address - Phone:410-484-8088
Practice Address - Fax:410-581-9485
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002153363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP20229Medicare UPIN