Provider Demographics
NPI:1083773634
Name:OLSSON, YOUNGSOOK THERESA (NP)
Entity Type:Individual
Prefix:
First Name:YOUNGSOOK
Middle Name:THERESA
Last Name:OLSSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:950 N MERIDIAN ST
Mailing Address - Street 2:STE 500 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-3908
Mailing Address - Country:US
Mailing Address - Phone:317-962-4942
Mailing Address - Fax:317-962-4950
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:RM AG 001
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-3886
Practice Address - Fax:317-962-8652
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008140363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200992510Medicaid
IN200992510Medicaid
INM400022780Medicare PIN
IN232230IIIIMedicare PIN