Healthcare Provider Details

I. General information

NPI: 1063101368
Provider Name (Legal Business Name): OLIVIA GRACE CODY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL LN STE 120
DANVILLE IN
46122-1993
US

IV. Provider business mailing address

1100 SOUTHFIELD DR STE 1370
PLAINFIELD IN
46168-4300
US

V. Phone/Fax

Practice location:
  • Phone: 317-745-7310
  • Fax:
Mailing address:
  • Phone: 317-837-5566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004044A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: