Healthcare Provider Details

I. General information

NPI: 1225296171
Provider Name (Legal Business Name): MRS. OLIVIA BOATRIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 CANNING DR
WEWAHITCHKA FL
32465-4710
US

IV. Provider business mailing address

612 CANNING DR
WEWAHITCHKA FL
32465-4710
US

V. Phone/Fax

Practice location:
  • Phone: 850-639-2274
  • Fax: 850-639-2274
Mailing address:
  • Phone: 850-639-2274
  • Fax: 850-639-2274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN515608
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: