Provider Demographics
NPI:1194007831
Name:OLSTHOORN, YAH
Entity Type:Individual
Prefix:
First Name:YAH
Middle Name:
Last Name:OLSTHOORN
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 1:2602 ASHLEY CLUB CIR
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-4322
Mailing Address - Country:US
Mailing Address - Phone:908-422-9310
Mailing Address - Fax:
Practice Address - Street 1:2602 ASHLEY CLUB CIR
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4322
Practice Address - Country:US
Practice Address - Phone:908-422-9310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2011019759172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver