Provider Demographics
NPI:1881628196
Name:OLSEN, KATHLEEN ANN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
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 1:707 ASH ST
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-1234
Mailing Address - Country:US
Mailing Address - Phone:715-635-2151
Mailing Address - Fax:715-635-8768
Practice Address - Street 1:707 ASH ST
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-1234
Practice Address - Country:US
Practice Address - Phone:715-635-2151
Practice Address - Fax:715-635-8768
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70557-030363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43825400Medicaid
WI43825400Medicaid
S17716Medicare UPIN