Provider Demographics
NPI:1225138431
Name:AJJA, OLIVIA (CRNA)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:AJJA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 HOGBACK RD
Mailing Address - Street 2:STE 5A
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9750
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-585-3023
Practice Address - Fax:248-585-3022
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704217534367500000X
OHAPRN.CRNA.019926367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOA217534OtherBLUE CROSS OF MI
OH0371798Medicaid
MI104465159Medicaid