Provider Demographics
NPI:1407568603
Name:SCISCO, OLIVIA (A-GNP-C)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:SCISCO
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 FIFTH AVE
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 LACEY RD # B
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:NJ
Practice Address - Zip Code:08759-1386
Practice Address - Country:US
Practice Address - Phone:732-849-1075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01377800363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology