Provider Demographics
NPI:1063125672
Name:MAYFIELD, OLIVIA SOUTHARD (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:SOUTHARD
Last Name:MAYFIELD
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3843 W RIVA CAPRI ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6739
Mailing Address - Country:US
Mailing Address - Phone:520-488-8568
Mailing Address - Fax:
Practice Address - Street 1:3015 E MAGIC VIEW DR STE 130
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3750
Practice Address - Country:US
Practice Address - Phone:208-482-5567
Practice Address - Fax:208-482-5515
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID74554363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology