Healthcare Provider Details

I. General information

NPI: 1225308406
Provider Name (Legal Business Name): MELISSA K ODLE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6294 STATE HIGHWAY 154
SESSER IL
62884-2163
US

IV. Provider business mailing address

PO BOX 155
CHRISTOPHER IL
62822-0155
US

V. Phone/Fax

Practice location:
  • Phone: 618-625-6979
  • Fax: 618-625-6979
Mailing address:
  • Phone: 618-724-2436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041344692
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017951
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.017951
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: