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General NPI Number Information
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NPI Number | 1154065670
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Entity Type | Individual
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Provider Name | OLIVIA N TISCKOS
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Gender | Female
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Dates
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Enumeration Date | 04/21/2022
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Last Update Date | 06/18/2025
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Provider Practice Location Address
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Address Line | 1122 WEST AVE APT 1
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City | NORMAL
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State | IL
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Zip | 61761-3472
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Country | US
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Telephone | 217-971-0937
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Fax |
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Provider Business Mailing Address
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Address Line | 239 YEOMAN DR
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City | SPRINGFIELD
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State | IL
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Zip | 62704-5246
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Country | US
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Telephone | 217-971-0937
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096005607
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License Number State | IL
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