Healthcare Provider Details

I. General information

NPI: 1497488779
Provider Name (Legal Business Name): MARY ALLEN OLSON APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 OAK TREE DR
HERNANDO MS
38632-1196
US

IV. Provider business mailing address

PO BOX 770
HERNANDO MS
38632-0770
US

V. Phone/Fax

Practice location:
  • Phone: 662-510-8606
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number905248
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: