Healthcare Provider Details

I. General information

NPI: 1780123877
Provider Name (Legal Business Name): OLIVIA GRACE ANNE CALDWELL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 CYPRESS GARDENS BLVD STE 270
WINTER HAVEN FL
33884-2241
US

IV. Provider business mailing address

16449 NELSON PARK DR APT 305
CLERMONT FL
34714-5863
US

V. Phone/Fax

Practice location:
  • Phone: 863-401-4401
  • Fax:
Mailing address:
  • Phone: 618-727-1235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2016026671
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: