Healthcare Provider Details

I. General information

NPI: 1477830974
Provider Name (Legal Business Name): MICHELLE CAROLINE O'DONNELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2011
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4460 RED BANK RD SU. 110
CINCINNATI OH
45227-2172
US

IV. Provider business mailing address

237 WILLIAM HOWARD TAFT RD 2ND FLOOR, CBO 2-3
CINCINNATI OH
45219-2610
US

V. Phone/Fax

Practice location:
  • Phone: 513-791-5200
  • Fax: 513-791-5229
Mailing address:
  • Phone: 513-791-5200
  • Fax: 513-791-5229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.003422
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: