Healthcare Provider Details

I. General information

NPI: 1669380309
Provider Name (Legal Business Name): OLIVIA WALLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9999 CANNON AFB, NM
APO AA
88103
US

IV. Provider business mailing address

5825 NW CONUS CT
PORT ST LUCIE FL
34986-3601
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-4917
  • Fax:
Mailing address:
  • Phone: 772-418-4084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: