Healthcare Provider Details

I. General information

NPI: 1104533348
Provider Name (Legal Business Name): OLEAN DENISE PITTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24224 MS HIGHWAY 15
MATHISTON MS
39752-6876
US

IV. Provider business mailing address

24224 MS HIGHWAY 15
MATHISTON MS
39752-6876
US

V. Phone/Fax

Practice location:
  • Phone: 662-263-3194
  • Fax:
Mailing address:
  • Phone: 662-263-3194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number002482
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number3996
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number002482
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: