MEDICARE: COLLETTE ODIBO APRN-CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	193806	MD
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	RN1058051	DC
3	163W00000X	Registered Nurse	624985	NY

General Provider Information

NPI Number	:	1255661294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLETTE ODIBO APRN-CNP

Provider Business Mailing Address
First Line	:	3501 GOLDEN HILL DR
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20721-2885
Country	:	US
Telephone Number	:	919-349-3177
Fax Number	:

Provider Business Practice Location Address
First Line	:	1818 NEW YORK AVE NE STE 110
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20002-1849
Country	:	US
Telephone Number	:	202-489-0615
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2010
Last Update Date	:	10/15/2021

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