Provider Demographics
NPI:1780990929
Name:OLSON, NICOLE M (LMP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:OLSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:HORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:PO BOX 562
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-0562
Mailing Address - Country:US
Mailing Address - Phone:425-335-3954
Mailing Address - Fax:
Practice Address - Street 1:1807 131ST DR NE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-9709
Practice Address - Country:US
Practice Address - Phone:425-335-3954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60168945225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist