Provider Demographics
NPI:1306469903
Name:HARDISON OLSEN, HAILLE (DO)
Entity type:Individual
Prefix:
First Name:HAILLE
Middle Name:
Last Name:HARDISON OLSEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 S WOODS DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3262
Mailing Address - Country:US
Mailing Address - Phone:321-636-3066
Mailing Address - Fax:321-636-2545
Practice Address - Street 1:1755 W HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2616
Practice Address - Country:US
Practice Address - Phone:321-724-5437
Practice Address - Fax:321-724-5570
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2023-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS19870208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program