Provider Demographics
NPI:1275009144
Name:SMITH, OLIVIA BRIELLE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:BRIELLE
Last Name:SMITH
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 1:4707 E 100 S
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47390-8512
Mailing Address - Country:US
Mailing Address - Phone:765-914-6518
Mailing Address - Fax:
Practice Address - Street 1:1870 QUAKER WAY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2499
Practice Address - Country:US
Practice Address - Phone:765-914-6518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer