Healthcare Provider Details

I. General information

NPI: 1609318708
Provider Name (Legal Business Name): OLIVIA MARK CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11889 SUNBURST MARBLE RD
RIVERVIEW FL
33579-2144
US

IV. Provider business mailing address

11889 SUNBURST MARBLE RD
RIVERVIEW FL
33579-2144
US

V. Phone/Fax

Practice location:
  • Phone: 609-456-2344
  • Fax:
Mailing address:
  • Phone: 609-456-2344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberCNA384563
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18KT00473700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: