Provider Demographics
NPI:1861700619
Name:HARGRAVE, MONTE DALE (RN)
Entity type:Individual
Prefix:MR
First Name:MONTE
Middle Name:DALE
Last Name:HARGRAVE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIT 15281 BOX 83
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205-5281
Mailing Address - Country:US
Mailing Address - Phone:01182104-095-5363
Mailing Address - Fax:
Practice Address - Street 1:UNIT 15281 BOX 83
Practice Address - Street 2:USAMEDDAC-KOREA MMC
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205
Practice Address - Country:US
Practice Address - Phone:01182104-095-5363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA586721163W00000X, 163WC0400X, 163WC1500X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADOOMedicare UPIN