Healthcare Provider Details

I. General information

NPI: 1689500183
Provider Name (Legal Business Name): MANDY JO ODEGAARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 16TH ST
GREELEY CO
80631-5154
US

IV. Provider business mailing address

625 SNOW PEAK CT
LOVELAND CO
80538-4638
US

V. Phone/Fax

Practice location:
  • Phone: 970-820-6114
  • Fax:
Mailing address:
  • Phone: 605-695-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberRN.1629067
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: