Healthcare Provider Details

I. General information

NPI: 1609235688
Provider Name (Legal Business Name): SEAN LUCIEN OLSEN DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 N MAIN ST
MANTI UT
84642-1254
US

IV. Provider business mailing address

46 N MAIN ST
MANTI UT
84642-1254
US

V. Phone/Fax

Practice location:
  • Phone: 435-835-7246
  • Fax: 435-835-7247
Mailing address:
  • Phone: 435-835-7246
  • Fax: 435-835-7247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6898945-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: