Provider Demographics
NPI:1902596695
Name:OLIVER, MYLANDA (FNP)
Entity Type:Individual
Prefix:
First Name:MYLANDA
Middle Name:
Last Name:OLIVER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 BROWNFIELD DR
Mailing Address - Street 2:
Mailing Address - City:EKRON
Mailing Address - State:KY
Mailing Address - Zip Code:40117-8658
Mailing Address - Country:US
Mailing Address - Phone:270-272-2843
Mailing Address - Fax:
Practice Address - Street 1:1602 AVENUE Q
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79401-4732
Practice Address - Country:US
Practice Address - Phone:469-809-6712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4001426163WG0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice