Healthcare Provider Details

I. General information

NPI: 1750986550
Provider Name (Legal Business Name): GRANT OLSEN CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25501 CHAGRIN BLVD STE 200
BEACHWOOD OH
44122-5603
US

IV. Provider business mailing address

PO BOX 378
SANDUSKY OH
44871-0378
US

V. Phone/Fax

Practice location:
  • Phone: 844-746-8537
  • Fax: 216-450-1810
Mailing address:
  • Phone: 419-626-6161
  • Fax: 419-502-3511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0027721
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0027721
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: