Provider Demographics
NPI:1124586185
Name:NEELY, OLIVIA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:NEELY
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 1:1939 FAIRMOUNT AVE UNIT 56202
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2047
Mailing Address - Country:US
Mailing Address - Phone:832-795-8009
Mailing Address - Fax:
Practice Address - Street 1:824 BETHLEHEM PIKE
Practice Address - Street 2:
Practice Address - City:SELLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18960-1403
Practice Address - Country:US
Practice Address - Phone:832-795-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered