Provider Demographics
NPI:1598548786
Name:MOLKENBUR, OLIVIA LUCILLE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LUCILLE
Last Name:MOLKENBUR
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 1:2316 W 23RD ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2373
Mailing Address - Country:US
Mailing Address - Phone:850-522-4770
Mailing Address - Fax:
Practice Address - Street 1:2316 W 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2373
Practice Address - Country:US
Practice Address - Phone:850-522-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT24508225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist