Healthcare Provider Details

I. General information

NPI: 1871277137
Provider Name (Legal Business Name): LYDIA LEA ODLIN SIMRILL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LYDIA LEA ODLIN

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W NINE MILE RD
PENSACOLA FL
32534-5307
US

IV. Provider business mailing address

1601 CUMMINS DR STE D
MODESTO CA
95358-6411
US

V. Phone/Fax

Practice location:
  • Phone: 850-746-4958
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9121339
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: