Healthcare Provider Details

I. General information

NPI: 1417811464
Provider Name (Legal Business Name): OLIVIA STEWART
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W I PKWY STE 208
DALLAS GA
30132-5103
US

IV. Provider business mailing address

300 W I PKWY STE 208
DALLAS GA
30132-5103
US

V. Phone/Fax

Practice location:
  • Phone: 770-694-6750
  • Fax: 770-818-5720
Mailing address:
  • Phone: 770-694-6750
  • Fax: 770-818-5720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN052747
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: