Provider Demographics
NPI:1386019628
Name:CRAIG, OLIVIA (RD)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:CRAIG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 WESTOVER DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-7360
Mailing Address - Country:US
Mailing Address - Phone:317-902-2820
Mailing Address - Fax:
Practice Address - Street 1:1306 WESTOVER DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-7360
Practice Address - Country:US
Practice Address - Phone:317-902-2820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-12
Last Update Date:2015-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1055133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered