Basic Information
| Provider Information | |||||||||
| NPI: | 1437222668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLENICK | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4155 YELLOWSTONE AVE | ||||||||
| Address2: | PINE RIDGE MALL | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832022345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082380020 | ||||||||
| FaxNumber: | 2082380021 | ||||||||
| Practice Location | |||||||||
| Address1: | 4155 YELLOWSTONE AVE | ||||||||
| Address2: | PINE RIDGE MALL | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832022345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082380020 | ||||||||
| FaxNumber: | 2082380021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | H-243 | ID | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 000010141365 | 01 | ID | REGENCE BCBS | OTHER | 0174362 | 01 | ID | WA DEPT OF LABOR | OTHER | AU-456 | 01 | ID | BLUE CROSS OF ID | OTHER | AU-449 | 01 | ID | BLUE CROSS GRP #AU-365 | OTHER | 000010150424 | 01 | ID | BLUE SHIELD OF ID | OTHER |