Provider Demographics
NPI:1790496081
Name:FLORES, OLIVIA NICOLE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:NICOLE
Last Name:FLORES
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 1:17666 WAXWING LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1387
Mailing Address - Country:US
Mailing Address - Phone:574-400-9310
Mailing Address - Fax:
Practice Address - Street 1:17666 WAXWING LN
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1387
Practice Address - Country:US
Practice Address - Phone:574-400-9310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer