Healthcare Provider Details

I. General information

NPI: 1225817786
Provider Name (Legal Business Name): JENNIFER OLMOS RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W KORTSEN RD
CASA GRANDE AZ
85122-5910
US

IV. Provider business mailing address

220 W KORTSEN RD
CASA GRANDE AZ
85122-5910
US

V. Phone/Fax

Practice location:
  • Phone: 520-423-0176
  • Fax:
Mailing address:
  • Phone: 520-423-0176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number240442
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: