Healthcare Provider Details

I. General information

NPI: 1215020078
Provider Name (Legal Business Name): MARLA M OLISH PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16555 MANCHESTER RD SUITE 100
GROVER MO
63040-1220
US

IV. Provider business mailing address

2201 WHITE ELM CT
CHESTERFIELD MO
63017-7282
US

V. Phone/Fax

Practice location:
  • Phone: 636-458-5858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number61038
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: