Healthcare Provider Details

I. General information

NPI: 1366276149
Provider Name (Legal Business Name): OLIVIA MACKENZIE KING PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4322 LAFAYETTE BLVD.
SOUTH BEND IN
46614
US

IV. Provider business mailing address

4322 LAFAYETTE BLVD.
SOUTH BEND IN
46614
US

V. Phone/Fax

Practice location:
  • Phone: 574-391-1111
  • Fax: 574-859-5040
Mailing address:
  • Phone: 574-391-1111
  • Fax: 574-859-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: