=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457704249
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIANA O'DONNELL FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2016
-----------------------------------------------------
Last Update Date | 03/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 775 POLE LINE RD W SUITE 112
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-5814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-814-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2669 4TH AVE E
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-7565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-420-3016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 53640
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------