Provider Demographics
NPI:1801349857
Name:DIXON, OLIVIA SUZANNE (CNM)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:SUZANNE
Last Name:DIXON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1687
Mailing Address - Country:US
Mailing Address - Phone:315-470-7903
Mailing Address - Fax:
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:POB NORTH, SUITE 4H
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-5875
Practice Address - Fax:315-492-3623
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001748367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife