Provider Demographics
NPI:1740439470
Name:OLSEN, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
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 1:1618 MILLENIUM WAY
Mailing Address - Street 2:STE 210
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6439
Mailing Address - Country:US
Mailing Address - Phone:208-884-4647
Mailing Address - Fax:208-884-8984
Practice Address - Street 1:1618 MILLENIUM WAY
Practice Address - Street 2:STE 210
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6439
Practice Address - Country:US
Practice Address - Phone:208-884-4647
Practice Address - Fax:208-884-8984
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2771225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1851457675Medicaid