Healthcare Provider Details

I. General information

NPI: 1124499801
Provider Name (Legal Business Name): MARISA OLSEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4021 COUNTY ROAD 210 W STE 5
ST JOHNS FL
32259-1180
US

IV. Provider business mailing address

201 SILKGRASS PL
ST JOHNS FL
32259-7432
US

V. Phone/Fax

Practice location:
  • Phone: 904-747-9802
  • Fax:
Mailing address:
  • Phone: 516-606-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11024675
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF338628
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: