Provider Demographics
NPI:1225746977
Name:GRAYSON, OLIVIA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9868 BEACH PORT DR
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4493
Mailing Address - Country:US
Mailing Address - Phone:218-522-0459
Mailing Address - Fax:
Practice Address - Street 1:8640 EAGLE CREEK CIR
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-4400
Practice Address - Country:US
Practice Address - Phone:952-746-7664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-11
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11022062363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health