Healthcare Provider Details

I. General information

NPI: 1568996635
Provider Name (Legal Business Name): OLIVIA REILLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 MEYERKORD AVE
NEWPORT RI
02841-1650
US

IV. Provider business mailing address

9259 BLUE SKY CT
OWINGS MD
20736-3328
US

V. Phone/Fax

Practice location:
  • Phone: 401-841-1248
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberAT00139
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: