Healthcare Provider Details

I. General information

NPI: 1871417725
Provider Name (Legal Business Name): IJEOMA ODEMENE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 433
MONTICELLO NY
12701-0433
US

IV. Provider business mailing address

PO BOX 433
MONTICELLO NY
12701-0433
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: --
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number408679
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: