Provider Demographics
NPI:1164876702
Name:OLSEN, ALICIA MARIE
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
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 1:110 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2507
Mailing Address - Country:US
Mailing Address - Phone:315-349-5511
Mailing Address - Fax:315-349-5921
Practice Address - Street 1:140 W 6TH ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2525
Practice Address - Country:US
Practice Address - Phone:315-349-5511
Practice Address - Fax:315-349-5823
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0086041133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86032629OtherCOMMISSION ON DIETETIC REGISTRATION
NY0086041OtherSTATE OF NEW YORK EDUCATION DEPARTMENT