=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326995960
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA OLSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2026
-----------------------------------------------------
Last Update Date | 03/12/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | N660 HWY 47
-----------------------------------------------------
City | KESHENA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54135-1125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-600-7865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1125
-----------------------------------------------------
City | KESHENA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54135-1125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-600-7865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172A00000X
-----------------------------------------------------
Taxonomy Name | Driver
-----------------------------------------------------
License Number | O4258138654402
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------