Basic Information
| Provider Information | |||||||||
| NPI: | 1366622961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'DELL | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10625 W NORTH AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532262315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148775350 | ||||||||
| FaxNumber: | 4148775360 | ||||||||
| Practice Location | |||||||||
| Address1: | 10625 W NORTH AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532262315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148775350 | ||||||||
| FaxNumber: | 4148775360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 363L00000X | 131693 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3315-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 331503333334 | 01 | WI | BLUE SHIELD | OTHER | 36052500 | 05 | WI | MEDICAID | 331503300004 | 01 | WI | BLUE SHIELD | OTHER |