Provider Demographics
NPI:1083353643
Name:OLSEN, MELISSA GLENN (FNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:GLENN
Last Name:OLSEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-5136
Mailing Address - Country:US
Mailing Address - Phone:435-640-6201
Mailing Address - Fax:
Practice Address - Street 1:5171 S COTTONWOOD ST STE 210
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5718
Practice Address - Country:US
Practice Address - Phone:801-507-3380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTF02220852363LF0000X
ID74993363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily