Provider Demographics
NPI:1588208094
Name:BALL, OLIVIA JANE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:JANE
Last Name:BALL
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:JANE
Other - Last Name:KEARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:340 STATELINE RD W
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1610
Mailing Address - Country:US
Mailing Address - Phone:662-579-3955
Mailing Address - Fax:
Practice Address - Street 1:340 STATELINE RD W
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1610
Practice Address - Country:US
Practice Address - Phone:662-579-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95043200163W00000X
MS905353363LP0808X
CA95018151363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse