Provider Demographics
NPI:1356167878
Name:DAVIS, OLIVIA
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:DAVIS
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 1:5244 SALTAMONTE DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-1276
Mailing Address - Country:US
Mailing Address - Phone:570-394-7708
Mailing Address - Fax:
Practice Address - Street 1:84 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18766-0997
Practice Address - Country:US
Practice Address - Phone:570-408-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-30
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2024058952363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily