Basic Information
| Provider Information | |||||||||
| NPI: | 1295222883 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODICIO | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | |||||||||
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| Credential: | ARNP, CPNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3255 FOREST HILL BLVD STE 107 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334065854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612757100 | ||||||||
| FaxNumber: | 5612757199 | ||||||||
| Practice Location | |||||||||
| Address1: | 3255 FOREST HILL BLVD STE 107 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334065854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612757100 | ||||||||
| FaxNumber: | 5612757199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2018 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | APRN9428908 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 24941400 | 05 | FL | MEDICAID |