Healthcare Provider Details

I. General information

NPI: 1306205265
Provider Name (Legal Business Name): KATHRYN OLIVER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 SABANA GRANDE AVE SE
RIO RANCHO NM
87124-1152
US

IV. Provider business mailing address

4210 SABANA GRANDE AVE SE
RIO RANCHO NM
87124-1152
US

V. Phone/Fax

Practice location:
  • Phone: 505-816-7534
  • Fax: 505-892-6606
Mailing address:
  • Phone: 505-816-7534
  • Fax: 505-892-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-164
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: