Basic Information
| Provider Information | |||||||||
| NPI: | 1114366523 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'DONNELL | ||||||||
| FirstName: | LEEANN | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 298 MEMORIAL DR | ||||||||
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| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296729443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644823100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2013 | ||||||||
| LastUpdateDate: | 10/13/2015 | ||||||||
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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 | 367500000X | 18322 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | NPI # | 01 | SC | BLUE CROSS | OTHER | 003167080A | 05 | GA | MEDICAID | AN2291 | 05 | SC | MEDICAID |