Provider Demographics
NPI:1760854772
Name:OLSEN, MONIQUE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:OLSEN
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 1:5501 GRAVES RD
Mailing Address - Street 2:
Mailing Address - City:GALWAY
Mailing Address - State:NY
Mailing Address - Zip Code:12074-2303
Mailing Address - Country:US
Mailing Address - Phone:518-242-6896
Mailing Address - Fax:
Practice Address - Street 1:5501 GRAVES RD
Practice Address - Street 2:
Practice Address - City:GALWAY
Practice Address - State:NY
Practice Address - Zip Code:12074-2303
Practice Address - Country:US
Practice Address - Phone:518-242-6896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY470300421172A00000X
NY384094536172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver