Basic Information
| Provider Information | |||||||||
| NPI: | 1083688295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'DELL | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | HEALTHCARE FOR THE HOMELESS OF MILWAUKEE, INC | ||||||||
| Address2: | 210 WEST CAPITOL DRIVE | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147276320 | ||||||||
| FaxNumber: | 4147276321 | ||||||||
| Practice Location | |||||||||
| Address1: | HEALTHCARE FOR THE HOMELESS OF MILWAUKEE, INC | ||||||||
| Address2: | 210 WEST CAPITOL DRIVE | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147276320 | ||||||||
| FaxNumber: | 4147276321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 131460-030 | WI | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | 3433-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0058230 | 05 | IA | MEDICAID |