Healthcare Provider Details

I. General information

NPI: 1316851553
Provider Name (Legal Business Name): JUSTIN JAMES OVERLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MELLON WAY
LATROBE PA
15650-1197
US

IV. Provider business mailing address

155 BARLOCK FRY RD
ACME PA
15610-2103
US

V. Phone/Fax

Practice location:
  • Phone: 724-537-2638
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN715387
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: