Healthcare Provider Details

I. General information

NPI: 1235170564
Provider Name (Legal Business Name): CAROL OLIVER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 MILL BEACH RD
BROOKINGS OR
97415-9690
US

IV. Provider business mailing address

PO BOX 5389
BROOKINGS OR
97415-0107
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-8700
  • Fax: 707-465-6166
Mailing address:
  • Phone: 541-412-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200650010NP FNP-PP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNPF9514
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: