Healthcare Provider Details

I. General information

NPI: 1821630575
Provider Name (Legal Business Name): OLIVIA ELLISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3469 NEW HIGHWAY 68
MADISONVILLE TN
37354-5148
US

IV. Provider business mailing address

3469 NEW HIGHWAY 68
MADISONVILLE TN
37354-5148
US

V. Phone/Fax

Practice location:
  • Phone: 423-442-3993
  • Fax:
Mailing address:
  • Phone: 423-442-3993
  • Fax: 423-442-9468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: