Healthcare Provider Details

I. General information

NPI: 1073175469
Provider Name (Legal Business Name): MARTHA CHANDANAIS OLMSTEAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 ASHMUN ST
SAULT SAINTE MARIE MI
49783-3711
US

IV. Provider business mailing address

97 S 4TH ST STE C
ISHPEMING MI
49849-2168
US

V. Phone/Fax

Practice location:
  • Phone: 906-632-2522
  • Fax: 906-632-2370
Mailing address:
  • Phone: 906-228-9699
  • Fax: 888-977-2109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number4704274514
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: