Provider Demographics
NPI:1629569330
Name:OLSEN, NICHOLAS J (HIS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:OLSEN
Suffix:
Gender:M
Credentials:HIS
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 310901
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36331-0901
Mailing Address - Country:US
Mailing Address - Phone:334-393-6688
Mailing Address - Fax:
Practice Address - Street 1:1930 EDWARDS LAKE RD STE 114
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3719
Practice Address - Country:US
Practice Address - Phone:205-267-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2301237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist