Healthcare Provider Details

I. General information

NPI: 1043486673
Provider Name (Legal Business Name): MARY KATHRYN ODAHL HELI NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2008
Last Update Date: 05/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOONE RD
BREMERTON WA
98312-1894
US

IV. Provider business mailing address

1 BOONE RD
BREMERTON WA
98312-1894
US

V. Phone/Fax

Practice location:
  • Phone: 360-475-4209
  • Fax:
Mailing address:
  • Phone: 360-475-4209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberR171005
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: