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General NPI Number Information
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NPI Number | 1114340411
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Entity Type | Individual
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Provider Name | OLIVIA NEELEY PA-C
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Gender | Female
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Dates
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Enumeration Date | 01/23/2014
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Last Update Date | 08/27/2021
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Provider Practice Location Address
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Address Line | 19 LESTER RD
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City | STATESBORO
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State | GA
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Zip | 30458-2119
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Country | US
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Telephone | 678-481-3479
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Fax |
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Provider Business Mailing Address
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Address Line | 1881 SS RAILROAD BED RD APT 2903
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City | STATESBORO
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State | GA
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Zip | 30461-8618
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Country | US
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Telephone | 678-481-3479
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | C05704
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | MA056713
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License Number State | PA
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