Healthcare Provider Details

I. General information

NPI: 1174072326
Provider Name (Legal Business Name): PAMELA OLIPHANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 F AVE
DOUGLAS AZ
85607-1919
US

IV. Provider business mailing address

155 CALLE PORTAL SUITE 100
SIERRA VISTA AZ
85635-2900
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-3285
  • Fax: 520-364-3378
Mailing address:
  • Phone: 520-459-3011
  • Fax: 520-515-8663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number706300
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: