Provider Demographics
NPI:1699786327
Name:OLAIVAR-LOMBOY, MARIETTA PANA (NP)
Entity type:Individual
Prefix:
First Name:MARIETTA
Middle Name:PANA
Last Name:OLAIVAR-LOMBOY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 KEITH DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-2947
Mailing Address - Country:US
Mailing Address - Phone:478-987-7444
Mailing Address - Fax:478-987-7747
Practice Address - Street 1:1018 KEITH DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-2948
Practice Address - Country:US
Practice Address - Phone:478-987-7444
Practice Address - Fax:478-987-7747
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA118138363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health