Provider Demographics
NPI:1851176465
Name:HARGRAVE, DELAINA
Entity Type:Individual
Prefix:
First Name:DELAINA
Middle Name:
Last Name:HARGRAVE
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 1:2420 BERRYMAN LN APT 1
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-2292
Mailing Address - Country:US
Mailing Address - Phone:409-659-4579
Mailing Address - Fax:
Practice Address - Street 1:1350 W NORTHERN LIGHTS BLVD STE C
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-3614
Practice Address - Country:US
Practice Address - Phone:907-334-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK212888225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist