Healthcare Provider Details

I. General information

NPI: 1750005575
Provider Name (Legal Business Name): ODALYS VIEDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 MULBERRY ST
SCRANTON PA
18510-2369
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-703-8231
  • Fax: 570-703-8250
Mailing address:
  • Phone: 570-703-8231
  • Fax: 570-703-8250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA067794
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: