Basic Information
| Provider Information | |||||||||
| NPI: | 1003429671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODIWO | ||||||||
| FirstName: | EDITH | ||||||||
| MiddleName: | LAMIRA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9908 CROSWELL ST | ||||||||
| Address2: | |||||||||
| City: | KELLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762442098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123645830 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2200 PASEO VERDE PKWY STE 190 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890522703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025894871 | ||||||||
| FaxNumber: | 7025894872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2020 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 1010544 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 838741 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.