Healthcare Provider Details

I. General information

NPI: 1093273831
Provider Name (Legal Business Name): HEIDI L OLSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 850
CHICAGO IL
60611-3124
US

IV. Provider business mailing address

280 N MARKET ST UNIT 212
BROOKFIELD WI
53045-3243
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-4517
  • Fax:
Mailing address:
  • Phone: 920-205-1371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.475186
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: