Healthcare Provider Details

I. General information

NPI: 1588848493
Provider Name (Legal Business Name): LEA MARIE O'DELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 BECK AVE MS 5-240
FAIRFIELD CA
94533-6804
US

IV. Provider business mailing address

14 LAVINA CT
ORINDA CA
94563-4213
US

V. Phone/Fax

Practice location:
  • Phone: 707-784-8158
  • Fax:
Mailing address:
  • Phone: 925-376-6572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number451618
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: