Provider Demographics
NPI:1609318708
Name:MARK, OLIVIA (CNA)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11889 SUNBURST MARBLE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2144
Mailing Address - Country:US
Mailing Address - Phone:609-456-2344
Mailing Address - Fax:
Practice Address - Street 1:11889 SUNBURST MARBLE RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-2144
Practice Address - Country:US
Practice Address - Phone:609-456-2344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA384563374U00000X
374U00000X, 3747A0650X
NJ18KT00473700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No374U00000XNursing Service Related ProvidersHome Health Aide
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider