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General NPI Number Information
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NPI Number | 1376193599
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Entity Type | Individual
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Provider Name | MIKKI LEANN OLIVER MA, LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 09/19/2019
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Last Update Date | 09/19/2019
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Provider Practice Location Address
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Address Line | 1350 KING COLLEGE RD
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City | BRISTOL
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State | TN
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Zip | 37620-2632
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Country | US
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Telephone | 423-652-6337
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Fax |
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Provider Business Mailing Address
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Address Line | 124 SJ OLIVER LOOP
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City | ELIZABETHTON
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State | TN
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Zip | 37643-4859
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Country | US
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Telephone |
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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 | 0126002098
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT0000001702
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License Number State | TN
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