Provider Demographics
NPI:1871340042
Name:OLSON, DALLIS
Entity type:Individual
Prefix:
First Name:DALLIS
Middle Name:
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 1:47 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-1113
Mailing Address - Country:US
Mailing Address - Phone:516-398-5716
Mailing Address - Fax:
Practice Address - Street 1:55 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4274
Practice Address - Country:US
Practice Address - Phone:516-536-2221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-04
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF353511363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily