Provider Demographics
NPI:1245427491
Name:OLSON, MICHELINE R (NP)
Entity Type:Individual
Prefix:
First Name:MICHELINE
Middle Name:R
Last Name:OLSON
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 3544
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-3544
Mailing Address - Country:US
Mailing Address - Phone:386-668-4402
Mailing Address - Fax:575-622-4023
Practice Address - Street 1:603 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5211
Practice Address - Country:US
Practice Address - Phone:575-622-1477
Practice Address - Fax:575-622-4023
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1992612363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily