Provider Demographics
NPI:1114952157
Name:OLSEN, KATHLEEN J (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:OLSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 152
Mailing Address - Street 2:
Mailing Address - City:SEDGWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04676-0152
Mailing Address - Country:US
Mailing Address - Phone:207-812-4353
Mailing Address - Fax:207-352-4080
Practice Address - Street 1:20 RADAR RD
Practice Address - Street 2:
Practice Address - City:SEDGWICK
Practice Address - State:ME
Practice Address - Zip Code:04676-2830
Practice Address - Country:US
Practice Address - Phone:207-812-4353
Practice Address - Fax:207-352-4080
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP181036363LP0808X
MARN205547363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAQ07955Medicare UPIN
MANP0583Medicare ID - Type Unspecified