Provider Demographics
NPI:1275885501
Name:OLENNIKOV, LEANNA A (OD)
Entity Type:Individual
Prefix:
First Name:LEANNA
Middle Name:A
Last Name:OLENNIKOV
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-3020
Mailing Address - Country:US
Mailing Address - Phone:802-775-2368
Mailing Address - Fax:802-775-2369
Practice Address - Street 1:198 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-3020
Practice Address - Country:US
Practice Address - Phone:802-775-2368
Practice Address - Fax:802-775-2369
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030.0133921152W00000X
VA0618002405152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4701609OtherCIGNA
VA1275885501Medicaid
VA548085OtherANTHEM BCBS