Provider Demographics
NPI:1912100512
Name:OLSON, SALLY ANN (LMP)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:ANN
Last Name:OLSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12702 148TH ST E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-9485
Mailing Address - Country:US
Mailing Address - Phone:253-312-8044
Mailing Address - Fax:
Practice Address - Street 1:502 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-5001
Practice Address - Country:US
Practice Address - Phone:253-312-8044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00008139174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA81819OtherLABOR & INDUSTRIES