Provider Demographics
NPI:1497163422
Name:VITA-FARNSWORTH, OLIVIA (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:VITA-FARNSWORTH
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5327
Mailing Address - Street 2:
Mailing Address - City:MISSISSIPPI STATE
Mailing Address - State:MS
Mailing Address - Zip Code:39762-5327
Mailing Address - Country:US
Mailing Address - Phone:662-325-2165
Mailing Address - Fax:662-325-5145
Practice Address - Street 1:288 LAKEVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:MISSISSIPPI STATE
Practice Address - State:MS
Practice Address - Zip Code:39762
Practice Address - Country:US
Practice Address - Phone:662-325-2165
Practice Address - Fax:662-325-5145
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260032042255A2300X
MSA9922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer