Provider Demographics
NPI:1356906341
Name:OLMSTED, LEAH SUZANNE
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:SUZANNE
Last Name:OLMSTED
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 1:3149 FAWN LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9008
Mailing Address - Country:US
Mailing Address - Phone:517-240-2431
Mailing Address - Fax:
Practice Address - Street 1:1001 LAURENCE AVE STE E
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2980
Practice Address - Country:US
Practice Address - Phone:517-750-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-05
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MILEOL14OtherHIPPA