Provider Demographics
NPI:1902260458
Name:ACOSTA, JULIA
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:ACOSTA
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 1:17882 SE MCLOUGHLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-6103
Mailing Address - Country:US
Mailing Address - Phone:503-353-9415
Mailing Address - Fax:
Practice Address - Street 1:17882 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-6103
Practice Address - Country:US
Practice Address - Phone:503-353-9415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR-10042-M164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR292910Medicaid