Healthcare Provider Details

I. General information

NPI: 1104417070
Provider Name (Legal Business Name): MARIE D OLSON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 PIEDMONT RD NE STE 620
ATLANTA GA
30305-1578
US

IV. Provider business mailing address

PO BOX 470
BACONTON GA
31716-0470
US

V. Phone/Fax

Practice location:
  • Phone: 404-835-3512
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN089277
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: