Healthcare Provider Details

I. General information

NPI: 1750273033
Provider Name (Legal Business Name): SHAWNA T OLSEN LE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2025
Last Update Date: 07/19/2025
Certification Date: 07/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19259 HIGHWAY 36
BLACHLY OR
97412-9740
US

IV. Provider business mailing address

19259 HIGHWAY 36
BLACHLY OR
97412-9740
US

V. Phone/Fax

Practice location:
  • Phone: 541-206-3139
  • Fax:
Mailing address:
  • Phone: 541-206-3139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberBAPE10249209
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: