Healthcare Provider Details

I. General information

NPI: 1679385603
Provider Name (Legal Business Name): JONATHON ERVIN OLMSTEAD RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 S KENNETH PL
CHANDLER AZ
85226-4645
US

IV. Provider business mailing address

339 S KENNETH PL
CHANDLER AZ
85226-4645
US

V. Phone/Fax

Practice location:
  • Phone: 480-766-9342
  • Fax:
Mailing address:
  • Phone: 480-766-9342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN209965
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: