Basic Information
| Provider Information | |||||||||
| NPI: | 1356642409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ODLE | ||||||||
| FirstName: | GIDGET | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | L.P.N. QMHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 COLES BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403524541 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 902 GALLIA ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405292125 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2010 | ||||||||
| LastUpdateDate: | 08/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | PN. 142056 | OH | N | Nursing Service Providers | Licensed Practical Nurse | 171M00000X | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.