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NPI Code Detail

MEDICARE: IVELISSE OLIVENCIA-SIMMONS NP

MEDICARE: IVELISSE OLIVENCIA-SIMMONS NP
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
1363L00000XNurse Practitioner79066ID
2363LA2100XAcute Care Nurse Practitioner5003363NC
3363L00000XNurse Practitioner5003363NC

General Provider Information

NPI Number : 1295931251
Entity Type Code : Individual
Provider Name (Legal Business Name) : IVELISSE OLIVENCIA-SIMMONS NP
Provider Business Mailing Address
First Line : PO BOX 744786
Second Line :
City : ATLANTA
State : GA
Zip : 30374-4786
Country : US
Telephone Number : 704-834-2450
Fax Number : 704-671-5331
Provider Business Practice Location Address
First Line : 2555 COURT DR STE 200
Second Line :
City : GASTONIA
State : NC
Zip : 28054-2178
Country : US
Telephone Number : 704-867-2141
Fax Number : 704-867-2308
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/26/2007
Last Update Date : 02/11/2025

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