Provider Demographics
NPI:1174072326
Name:OLIPHANT, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:OLIPHANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CALLE PORTAL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2900
Mailing Address - Country:US
Mailing Address - Phone:520-459-3011
Mailing Address - Fax:520-515-8663
Practice Address - Street 1:1100 F AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-1919
Practice Address - Country:US
Practice Address - Phone:520-364-3285
Practice Address - Fax:520-364-3378
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
706300133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered