1265916811 NPI number — KIERSTIN LEIGH OLSON L.AC, MSOM, BS

Table of content: KIERSTIN LEIGH OLSON L.AC, MSOM, BS (NPI 1265916811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265916811 NPI number — KIERSTIN LEIGH OLSON L.AC, MSOM, BS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLSON
Provider First Name:
KIERSTIN
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.AC, MSOM, BS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265916811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1270 TIMBERSHORE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55123-1019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-329-6815
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3546 DAKOTA AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416-2313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-417-6433
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  1853 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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