Provider Demographics
NPI:1164290706
Name:ELLIS, OLIVIA MAE (LDO, ABOC)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MAE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LDO, ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BURNT BRIDGE WAY APT E
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-4747
Mailing Address - Country:US
Mailing Address - Phone:757-509-1655
Mailing Address - Fax:
Practice Address - Street 1:6819 WALTONS LN
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-6113
Practice Address - Country:US
Practice Address - Phone:804-693-2623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101004052156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician