Provider Demographics
NPI:1912694183
Name:OLSON, SHANNON ALISA
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ALISA
Last Name:OLSON
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 1:13838 THE LAKES BLVD APT 6210
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-5651
Mailing Address - Country:US
Mailing Address - Phone:817-653-3038
Mailing Address - Fax:
Practice Address - Street 1:13838 THE LAKES BLVD APT 6210
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-5651
Practice Address - Country:US
Practice Address - Phone:817-653-3038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX754094163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse