Provider Demographics
NPI:1780123877
Name:CALDWELL, OLIVIA GRACE ANNE (ATC)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GRACE ANNE
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16449 NELSON PARK DR APT 305
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-5863
Mailing Address - Country:US
Mailing Address - Phone:618-727-1235
Mailing Address - Fax:
Practice Address - Street 1:5535 CYPRESS GARDENS BLVD STE 270
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-2241
Practice Address - Country:US
Practice Address - Phone:863-401-4401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160266712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer