MEDICARE: MRS. OLIVIA BROOKE WRIGHT NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	0024179653	VA
2	363LG0600X	Gerontology Nurse Practitioner	0024179653	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0024179653	OTHER	VA	LICENSE NO.

General Provider Information

NPI Number	:	1558989186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. OLIVIA BROOKE WRIGHT NP

Provider Business Mailing Address
First Line	:	2451 MIDTOWN AVE APT 1317
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22303-1437
Country	:	US
Telephone Number	:	740-361-8212
Fax Number	:

Provider Business Practice Location Address
First Line	:	2451 MIDTOWN AVE APT 1317
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22303-1437
Country	:	US
Telephone Number	:	740-361-8212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2020
Last Update Date	:	07/22/2020

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