Healthcare Provider Details

I. General information

NPI: 1053788422
Provider Name (Legal Business Name): LUCKRICIA OLIVACCE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 PROFESSIONAL CT SUITE P
HAGERSTOWN MD
21740-4100
US

IV. Provider business mailing address

11350 MCCORMICK RD EXECUTIVE PLAZA 1, SUITE 501
HUNT VALLEY MD
21031-1002
US

V. Phone/Fax

Practice location:
  • Phone: 301-665-9696
  • Fax: 240-420-5715
Mailing address:
  • Phone: 301-669-9696
  • Fax: 240-420-5715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0005876
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: