Provider Demographics
NPI:1508946914
Name:OLSON, LUANN
Entity Type:Individual
Prefix:
First Name:LUANN
Middle Name:
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 1:204 S MAIN
Mailing Address - Street 2:
Mailing Address - City:ALEXIS
Mailing Address - State:IL
Mailing Address - Zip Code:61412
Mailing Address - Country:US
Mailing Address - Phone:309-482-5571
Mailing Address - Fax:309-482-5530
Practice Address - Street 1:204 S MAIN
Practice Address - Street 2:
Practice Address - City:ALEXIS
Practice Address - State:IL
Practice Address - Zip Code:61412
Practice Address - Country:US
Practice Address - Phone:309-482-5571
Practice Address - Fax:309-482-5530
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041198284/209005287363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCB6569Medicare ID - Type UnspecifiedRR GROUP #
IL210745Medicare ID - Type UnspecifiedGROUP #
Q32996Medicare UPIN
ILP00223045Medicare ID - Type UnspecifiedRR INDIVIDUAL #
ILK13814Medicare ID - Type UnspecifiedINDIVIDUAL #