Basic Information
| Provider Information | |||||||||
| NPI: | 1174072326 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLIPHANT | ||||||||
| FirstName: | PAMELA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 CALLE PORTAL | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856352900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204593011 | ||||||||
| FaxNumber: | 5205158663 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 F AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856071919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203643285 | ||||||||
| FaxNumber: | 5203643378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2016 | ||||||||
| LastUpdateDate: | 11/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 706300 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.