Provider Demographics
NPI:1902193527
Name:OLSON-CASSIDY, KENDALL LEE
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:LEE
Last Name:OLSON-CASSIDY
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:541-732-7460
Mailing Address - Fax:541-732-7461
Practice Address - Street 1:940 ROYAL AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6193
Practice Address - Country:US
Practice Address - Phone:541-732-7460
Practice Address - Fax:541-732-7461
Is Sole Proprietor?:No
Enumeration Date:2011-07-03
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201042785RN163W00000X
OR201250156NP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse