Healthcare Provider Details

I. General information

NPI: 1629772736
Provider Name (Legal Business Name): VICKY OLIVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA LARA OLIVA FNP-BC

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3431 BROADWAY ST
AMERICAN CANYON CA
94503-1228
US

IV. Provider business mailing address

1179 N MCDOWELL BLVD
PETALUMA CA
94954-1110
US

V. Phone/Fax

Practice location:
  • Phone: 707-492-5014
  • Fax:
Mailing address:
  • Phone: 707-492-5014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95041354
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: