Basic Information
| Provider Information | |||||||||
| NPI: | 1730669219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULL | ||||||||
| FirstName: | OLIVIA | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7551 9TH ST N STE 100 | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551286628 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2515 WHITE BEAR AVE N STE A11 | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551095118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512754706 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2018 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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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 | 225100000X | 11222 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.