Healthcare Provider Details

I. General information

NPI: 1346281946
Provider Name (Legal Business Name): KELLIE OLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92354
US

IV. Provider business mailing address

PO BOX 2000 11234 ANDERSON ST ROOM MC-A108
LOMA LINDA CA
92354
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4344
  • Fax:
Mailing address:
  • Phone: 909-558-4344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD00043240
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA100120
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: