Provider Demographics
NPI:1164512273
Name:OLSON, KATHERINE S (LRD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:S
Last Name:OLSON
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:S
Other - Last Name:STEPHANIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LRD
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:701-234-1012
Practice Address - Street 1:1717 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4939
Practice Address - Country:US
Practice Address - Phone:701-234-2000
Practice Address - Fax:701-234-2345
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND632133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51339Medicaid
ND712159Medicare PIN