Healthcare Provider Details

I. General information

NPI: 1083353643
Provider Name (Legal Business Name): MELISSA GLENN OLSEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5171 S COTTONWOOD ST STE 210
MURRAY UT
84107-5718
US

IV. Provider business mailing address

610 OAKLAND AVE
AUSTIN TX
78703-5136
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3380
  • Fax:
Mailing address:
  • Phone: 435-640-6201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF02220852
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number74993
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: