Provider Demographics
NPI:1114638566
Name:OLSON, TRACY M (PMHNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:OLSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17922 HOMESTEAD BLUFFS DR
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-8435
Mailing Address - Country:US
Mailing Address - Phone:636-233-7418
Mailing Address - Fax:
Practice Address - Street 1:11477 OLDE CABIN RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7130
Practice Address - Country:US
Practice Address - Phone:314-569-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022046847363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health