Provider Demographics
NPI:1134105364
Name:OLSEN, LISA JANE (APRN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:JANE
Last Name:OLSEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 E 60 S
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3835
Mailing Address - Country:US
Mailing Address - Phone:801-302-2017
Mailing Address - Fax:
Practice Address - Street 1:361 E 1200 S STE 201
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-6904
Practice Address - Country:US
Practice Address - Phone:801-224-3014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT345768-4405363LP0808X
UT345768-3102163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU006 107030993101Medicaid
UTU002 802665Medicaid
UTU003 666Medicaid
UTU006 107030993101Medicaid