Provider Demographics
NPI:1316710445
Name:MOUNTCASTLE, OLIVIA LOUISE (RDN LDN MS)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LOUISE
Last Name:MOUNTCASTLE
Suffix:
Gender:F
Credentials:RDN LDN MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-8642
Mailing Address - Country:US
Mailing Address - Phone:307-739-7361
Mailing Address - Fax:
Practice Address - Street 1:625 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-739-7361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY499133VN1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Oncology