Healthcare Provider Details

I. General information

NPI: 1013679042
Provider Name (Legal Business Name): SAMANTHA JO OLSON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 10/07/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 DELMORE DR
ROSEAU MN
56751-1599
US

IV. Provider business mailing address

715 DELMORE DR
ROSEAU MN
56751-1534
US

V. Phone/Fax

Practice location:
  • Phone: 218-463-2500
  • Fax:
Mailing address:
  • Phone: 218-463-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8481
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: