Healthcare Provider Details

I. General information

NPI: 1275186579
Provider Name (Legal Business Name): LYDIA E ODELL MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. LYDIA E MARTIN

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E NORTH AVE
CAROL STREAM IL
60188-2127
US

IV. Provider business mailing address

630 E NORTH AVE
CAROL STREAM IL
60188-2127
US

V. Phone/Fax

Practice location:
  • Phone: 630-861-6663
  • Fax: 630-861-0758
Mailing address:
  • Phone: 630-861-6663
  • Fax: 630-331-0758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209018878
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: