Provider Demographics
NPI:1174023501
Name:OLIVENCIA, CHRISTINE LAUREN
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:LAUREN
Last Name:OLIVENCIA
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 1:11 CAPRON ST
Mailing Address - Street 2:
Mailing Address - City:WALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:12586-1209
Mailing Address - Country:US
Mailing Address - Phone:845-551-6721
Mailing Address - Fax:
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3816
Practice Address - Country:US
Practice Address - Phone:516-562-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant