Healthcare Provider Details

I. General information

NPI: 1710512744
Provider Name (Legal Business Name): LOLITA ALANNA ODIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 SW 36TH ST
SAN ANTONIO TX
78237-3360
US

IV. Provider business mailing address

PO BOX 734812
DALLAS TX
75373-4812
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-5100
  • Fax:
Mailing address:
  • Phone: 210-358-9500
  • Fax: 210-358-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP142785
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP142785
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: