Provider Demographics
NPI:1609569748
Name:FLEETWOOD, OLIVIA OPAL (DNP, CRNA)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:OPAL
Last Name:FLEETWOOD
Suffix:
Gender:F
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:OPAL
Other - Last Name:BOLDOSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:94 MELLEN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2141
Mailing Address - Country:US
Mailing Address - Phone:740-803-0615
Mailing Address - Fax:
Practice Address - Street 1:175 FORE RIVER PKWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2779
Practice Address - Country:US
Practice Address - Phone:207-879-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERNA233010367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered