Healthcare Provider Details

I. General information

NPI: 1790511798
Provider Name (Legal Business Name): OLIVIA ROSE OMALLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SPRUCE ST UNIT B
PHILADELPHIA PA
19107-6192
US

IV. Provider business mailing address

301 S 8TH ST STE 2L
PHILADELPHIA PA
19106-4017
US

V. Phone/Fax

Practice location:
  • Phone: 856-649-2810
  • Fax:
Mailing address:
  • Phone: 267-322-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number151784
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: