Provider Demographics
NPI:1376161059
Name:DOUGLAS, OCTAVIA
Entity Type:Individual
Prefix:MRS
First Name:OCTAVIA
Middle Name:
Last Name:DOUGLAS
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 1:70 HIGHLAND PARK DR
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19056-1338
Mailing Address - Country:US
Mailing Address - Phone:908-954-8942
Mailing Address - Fax:
Practice Address - Street 1:70 HIGHLAND PARK DR
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:PA
Practice Address - Zip Code:19056-1338
Practice Address - Country:US
Practice Address - Phone:908-954-8942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN309164164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty