Provider Demographics
NPI:1114340411
Name:NEELEY, OLIVIA (PA-C)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:NEELEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 SS RAILROAD BED RD APT 2903
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30461-8618
Mailing Address - Country:US
Mailing Address - Phone:678-481-3479
Mailing Address - Fax:
Practice Address - Street 1:19 LESTER RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2119
Practice Address - Country:US
Practice Address - Phone:678-481-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC05704363A00000X
GA363AM0700X
PAMA056713363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant