Healthcare Provider Details

I. General information

NPI: 1881482412
Provider Name (Legal Business Name): OLIVIA MICHELLE HISCOX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 CORPORATE HILL DR
SAINT LOUIS MO
63131-1845
US

IV. Provider business mailing address

11942 DEVONSHIRE AVE
DES PERES MO
63131-4509
US

V. Phone/Fax

Practice location:
  • Phone: 557-203-4112
  • Fax:
Mailing address:
  • Phone: 314-471-7251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2025026590
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: