Healthcare Provider Details

I. General information

NPI: 1073880621
Provider Name (Legal Business Name): MARIKO LEE ODHNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIKO LEE JAMESON

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 UNION ST
LYNN MA
01901-1314
US

IV. Provider business mailing address

325 MAIN ST
MEDFORD MA
02155-6152
US

V. Phone/Fax

Practice location:
  • Phone: 781-596-2502
  • Fax: 781-596-3966
Mailing address:
  • Phone: 617-519-8246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP37010
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2268187
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: