Provider Demographics
NPI:1205658119
Name:QUEEN, OLIVIA M
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:M
Last Name:QUEEN
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 1:7437 SEAL BEACH CT
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-4461
Mailing Address - Country:US
Mailing Address - Phone:928-234-1039
Mailing Address - Fax:
Practice Address - Street 1:283 CONSTITUTION DR STE 600
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6760
Practice Address - Country:US
Practice Address - Phone:757-250-7725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program