Provider Demographics
NPI:1871216812
Name:JUENGST, OLIVIA RAVEN
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:RAVEN
Last Name:JUENGST
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 1:4294 CALAVO DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7008
Mailing Address - Country:US
Mailing Address - Phone:619-724-9765
Mailing Address - Fax:
Practice Address - Street 1:4294 CALAVO DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7008
Practice Address - Country:US
Practice Address - Phone:619-724-9765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01232368376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide