Healthcare Provider Details

I. General information

NPI: 1477017630
Provider Name (Legal Business Name): NICOLE MARIE ODEM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 E STATE ST
SHARON PA
16146-3328
US

IV. Provider business mailing address

1515 CHARLES ST
HERMITAGE PA
16148-2052
US

V. Phone/Fax

Practice location:
  • Phone: 724-658-7790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: