Provider Demographics
NPI:1619235504
Name:LEE OLSON, LAURA KAY
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KAY
Last Name:LEE 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 1:2650 JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-3474
Mailing Address - Country:US
Mailing Address - Phone:605-341-8000
Mailing Address - Fax:605-341-8003
Practice Address - Street 1:2650 JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3474
Practice Address - Country:US
Practice Address - Phone:605-341-8000
Practice Address - Fax:605-341-8003
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDNOT REQUIRED251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health