Provider Demographics
NPI:1255007761
Name:OLSON, LACI ROSE
Entity Type:Individual
Prefix:
First Name:LACI
Middle Name:ROSE
Last Name:OLSON
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 1:24 GREAT PLAINS ROAD
Mailing Address - Street 2:
Mailing Address - City:ARAPAHOE
Mailing Address - State:WY
Mailing Address - Zip Code:82524-0000
Mailing Address - Country:US
Mailing Address - Phone:307-856-0470
Mailing Address - Fax:
Practice Address - Street 1:24 GREAT PLAINS ROAD
Practice Address - Street 2:
Practice Address - City:ARAPAHOE
Practice Address - State:WY
Practice Address - Zip Code:82524-8252
Practice Address - Country:US
Practice Address - Phone:307-856-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCAPA-079172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker