Healthcare Provider Details

I. General information

NPI: 1306469903
Provider Name (Legal Business Name): HAILLE HARDISON OLSEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 10/21/2023
Certification Date: 10/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 W HIBISCUS BLVD
MELBOURNE FL
32901-2616
US

IV. Provider business mailing address

134 S WOODS DR
ROCKLEDGE FL
32955-3262
US

V. Phone/Fax

Practice location:
  • Phone: 321-724-5437
  • Fax: 321-724-5570
Mailing address:
  • Phone: 321-636-3066
  • Fax: 321-636-2545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS19870
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: