Healthcare Provider Details

I. General information

NPI: 1730814260
Provider Name (Legal Business Name): HEIDI LISA ODUM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 PLEASANT STREET, SUITE G300
CONCORD NH
03301
US

IV. Provider business mailing address

248 PLEASANT ST STE G300
CONCORD NH
03301-7530
US

V. Phone/Fax

Practice location:
  • Phone: 603-224-9995
  • Fax: 603-226-0859
Mailing address:
  • Phone: 603-224-9995
  • Fax: 603-226-0859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number064437-23
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number064437-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: