MEDICARE: MS. RAINEY REANNA OLLIFF PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	363AM0700X	Medical Physician Assistant		GA

General Provider Information

NPI Number	:	1073023461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. RAINEY REANNA OLLIFF PA-C

Provider Business Mailing Address
First Line	:	1223 FOREST ST
Second Line	:
City	:	SAINT SIMONS ISLAND
State	:	GA
Zip	:	31522-4214
Country	:	US
Telephone Number	:	912-675-5578
Fax Number	:

Provider Business Practice Location Address
First Line	:	1223 FOREST ST
Second Line	:
City	:	SAINT SIMONS ISLAND
State	:	GA
Zip	:	31522-4214
Country	:	US
Telephone Number	:	912-675-5578
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2017
Last Update Date	:	10/11/2017

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