Provider Demographics
NPI:1447014378
Name:OLSEN, MARISSA MICHELLE (LN, CNS)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:MICHELLE
Last Name:OLSEN
Suffix:
Gender:F
Credentials:LN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 BUCHANAN ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2252
Mailing Address - Country:US
Mailing Address - Phone:612-978-5124
Mailing Address - Fax:
Practice Address - Street 1:3115 BUCHANAN ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-2252
Practice Address - Country:US
Practice Address - Phone:612-978-5124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN236133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist