Provider Demographics
NPI:1982235008
Name:OLIVAS, LEANNA MARIE
Entity type:Individual
Prefix:
First Name:LEANNA
Middle Name:MARIE
Last Name:OLIVAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1047 SEACOAST DR APT 4
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2519
Mailing Address - Country:US
Mailing Address - Phone:626-488-1983
Mailing Address - Fax:
Practice Address - Street 1:1047 SEACOAST DR APT 4
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-2519
Practice Address - Country:US
Practice Address - Phone:626-488-1983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF2083176OtherDRIVER LICENSE