Basic Information
| Provider Information | |||||||||
| NPI: | 1134188808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODONNELL | ||||||||
| FirstName: | JULIE | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PONCHATOULA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704542532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9853707546 | ||||||||
| FaxNumber: | 9853707765 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PONCHATOULA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704542532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9853707546 | ||||||||
| FaxNumber: | 9853707765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 08/06/2013 | ||||||||
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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 | 363AM0700X | PA.200127.RX | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1190888 | 05 | LA | MEDICAID |