Provider Demographics
NPI:1023191327
Name:GROTEGUTH, JULIE RANAE
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:RANAE
Last Name:GROTEGUTH
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 1:11401 S OLD 41
Mailing Address - Street 2:
Mailing Address - City:OAKTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47561-8907
Mailing Address - Country:US
Mailing Address - Phone:812-887-9980
Mailing Address - Fax:
Practice Address - Street 1:2920 10TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-6602
Practice Address - Country:US
Practice Address - Phone:812-376-9404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN703494373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200637450Medicaid