Provider Demographics
NPI:1639381767
Name:DIEHL, OLIVIA A
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:A
Last Name:DIEHL
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 1:328 CHESTNUT STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:44077-5708
Mailing Address - Country:US
Mailing Address - Phone:440-655-9219
Mailing Address - Fax:
Practice Address - Street 1:328 CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:FAIRPORT HARBOR
Practice Address - State:OH
Practice Address - Zip Code:44077-5708
Practice Address - Country:US
Practice Address - Phone:440-655-9219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN . 117928 MEDS164X00000X
OHRN.337631163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2704630Medicaid