MEDICARE: OLIVIA GLEASON

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

General Provider Information

NPI Number	:	1124756259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA GLEASON

Provider Business Mailing Address
First Line	:	218 JUNIPER DR
Second Line	:
City	:	LANCASTER
State	:	PA
Zip	:	17602-1399
Country	:	US
Telephone Number	:	717-517-1632
Fax Number	:

Provider Business Practice Location Address
First Line	:	4619 WOODLAND AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-3862
Country	:	US
Telephone Number	:	215-596-7140
Fax Number	:

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

Provider Enumeration Date	:	08/08/2022
Last Update Date	:	08/09/2022

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