Provider Demographics
NPI:1619337011
Name:JOHNTRY, OLIVIA MICHELLE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MICHELLE
Last Name:JOHNTRY
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 1:3050 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-8124
Mailing Address - Country:US
Mailing Address - Phone:929-348-4492
Mailing Address - Fax:
Practice Address - Street 1:1500 WATERS PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2723
Practice Address - Country:US
Practice Address - Phone:929-348-4492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist