Provider Demographics
NPI:1326778838
Name:FENTY, OLIVIA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:FENTY
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 1:2 WEYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-3317
Mailing Address - Country:US
Mailing Address - Phone:857-888-7326
Mailing Address - Fax:
Practice Address - Street 1:99 DAY ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-4335
Practice Address - Country:US
Practice Address - Phone:978-345-0685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty