Provider Demographics
NPI:1659745461
Name:EASTMOND, JULIANNE
Entity Type:Individual
Prefix:
First Name:JULIANNE
Middle Name:
Last Name:EASTMOND
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 1:4504 LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-1627
Mailing Address - Country:US
Mailing Address - Phone:239-798-8764
Mailing Address - Fax:
Practice Address - Street 1:4504 LEE BLVD
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-1627
Practice Address - Country:US
Practice Address - Phone:239-798-8764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906763311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015293000Medicaid
FL6906763OtherAHCA