Healthcare Provider Details

I. General information

NPI: 1023372117
Provider Name (Legal Business Name): PETER O'DONNELL NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 PARK AVE
PORTLAND ME
04102-2957
US

IV. Provider business mailing address

180 PARK AVE
PORTLAND ME
04102-2957
US

V. Phone/Fax

Practice location:
  • Phone: 207-828-2402
  • Fax: 207-828-2425
Mailing address:
  • Phone: 207-874-2141
  • Fax: 207-874-2164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number21443315
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP121035
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: