Provider Demographics
NPI:1760525711
Name:OLSEN, LEANNA RAE (RN, CMT)
Entity Type:Individual
Prefix:MS
First Name:LEANNA
Middle Name:RAE
Last Name:OLSEN
Suffix:
Gender:F
Credentials:RN, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 TRENTON CIR
Mailing Address - Street 2:
Mailing Address - City:MCLOUD
Mailing Address - State:OK
Mailing Address - Zip Code:74851-9512
Mailing Address - Country:US
Mailing Address - Phone:405-964-5378
Mailing Address - Fax:
Practice Address - Street 1:1500 N. KICKAPOO, SUITE #4
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804
Practice Address - Country:US
Practice Address - Phone:405-214-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0035490163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse