Provider Demographics
NPI:1053798801
Name:OLSON, LISA LYNN (LPN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:OLSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 77
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-0077
Mailing Address - Country:US
Mailing Address - Phone:651-829-5416
Mailing Address - Fax:
Practice Address - Street 1:17410 BANYAN RD
Practice Address - Street 2:
Practice Address - City:SHAFER
Practice Address - State:MN
Practice Address - Zip Code:55074-9675
Practice Address - Country:US
Practice Address - Phone:651-829-5416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL040235-2164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse