Provider Demographics
NPI:1851064828
Name:NIEDBALA, OLIVIA R (LAC)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:R
Last Name:NIEDBALA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BENNETT AVE STE 2C
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-9760
Mailing Address - Country:US
Mailing Address - Phone:570-832-8600
Mailing Address - Fax:
Practice Address - Street 1:104 BENNETT AVE STE 2C
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18337-9760
Practice Address - Country:US
Practice Address - Phone:570-832-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOM000257171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist