Healthcare Provider Details

I. General information

NPI: 1710500624
Provider Name (Legal Business Name): KATHLEEN O'DONNELL PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 07/03/2023
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

417 EVERWILD LN
MACEDON NY
14502-9395
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-7150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number383105
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: