Provider Demographics
NPI:1265843346
Name:OLSON, SHANNON (ATC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 34TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-6938
Mailing Address - Country:US
Mailing Address - Phone:701-866-5298
Mailing Address - Fax:
Practice Address - Street 1:800 40TH AVE E
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-7926
Practice Address - Country:US
Practice Address - Phone:701-356-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND251-02246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other