Healthcare Provider Details

I. General information

NPI: 1104330109
Provider Name (Legal Business Name): KATHLEEN SUZANNE ODELL CRNP-FAMILY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 E BALTIMORE ST
BALTIMORE MD
21202-4705
US

IV. Provider business mailing address

PO BOX 103
SEVERNA PARK MD
21146-0103
US

V. Phone/Fax

Practice location:
  • Phone: 410-675-7500
  • Fax: 443-230-0059
Mailing address:
  • Phone: 410-675-7500
  • Fax: 443-230-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR128442
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: