Provider Demographics
NPI:1396295325
Name:OLIVAREZ, MARK VINCENT (MSN FNP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:VINCENT
Last Name:OLIVAREZ
Suffix:
Gender:M
Credentials:MSN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 N KENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-1418
Mailing Address - Country:US
Mailing Address - Phone:323-540-3417
Mailing Address - Fax:
Practice Address - Street 1:1817 N KENWOOD ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-1418
Practice Address - Country:US
Practice Address - Phone:323-540-3417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2021-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005145363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily