Healthcare Provider Details

I. General information

NPI: 1063412542
Provider Name (Legal Business Name): EILEEN JOY ODONNELL RN, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 MONTAUK AVE
NEW LONDON CT
06320-4738
US

IV. Provider business mailing address

146 IRONWORKS RD
CLINTON CT
06413-1223
US

V. Phone/Fax

Practice location:
  • Phone: 860-444-6711
  • Fax: 860-437-0650
Mailing address:
  • Phone: 860-664-0466
  • Fax: 860-669-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number000368
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: