Healthcare Provider Details

I. General information

NPI: 1942290804
Provider Name (Legal Business Name): COLLEEN ODONNELL P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2132 N 1700 W STE 230
LAYTON UT
84041-7060
US

IV. Provider business mailing address

4017 N WOLF CREEK DR
EDEN UT
84310-9894
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-3900
  • Fax: 801-773-3900
Mailing address:
  • Phone: 801-690-6456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007859-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number6526009-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: