Healthcare Provider Details

I. General information

NPI: 1487618062
Provider Name (Legal Business Name): ANGELA SUZZANNE OLOMON DO, FACN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E SAN MARTIN ST
BOLIVAR MO
65613-2893
US

IV. Provider business mailing address

PO BOX 49
BOLIVAR MO
65613-0049
US

V. Phone/Fax

Practice location:
  • Phone: 417-326-7272
  • Fax: 417-326-2193
Mailing address:
  • Phone: 417-326-7272
  • Fax: 417-326-2193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR1J41
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: