Healthcare Provider Details

I. General information

NPI: 1487576369
Provider Name (Legal Business Name): GEORGETTE OLIVE MA-P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 W 3RD ST APT 7
MISHAWAKA IN
46544-1771
US

IV. Provider business mailing address

807 W 3RD ST APT 7
MISHAWAKA IN
46544-1771
US

V. Phone/Fax

Practice location:
  • Phone: 317-522-1170
  • Fax:
Mailing address:
  • Phone: 317-522-1170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberMAPC.PC.60666666
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: