Provider Demographics
NPI:1104196351
Name:OLSEN, BRANDICE
Entity Type:Individual
Prefix:
First Name:BRANDICE
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14700 28TH AVE N
Mailing Address - Street 2:SUITE 20
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4835
Mailing Address - Country:US
Mailing Address - Phone:763-559-3779
Mailing Address - Fax:763-450-3986
Practice Address - Street 1:4100 LAKE OTIS PKWY
Practice Address - Street 2:SUITE 222
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5229
Practice Address - Country:US
Practice Address - Phone:907-550-6100
Practice Address - Fax:907-550-6268
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2014-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201140700RN390200000X
AK432367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program