Basic Information
| Provider Information | |||||||||
| NPI: | 1669041067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODLUM | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 W COLUMBIA ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477101656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124503363 | ||||||||
| FaxNumber: | 8124503071 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 W COLUMBIA ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477101656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124503363 | ||||||||
| FaxNumber: | 8124503071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2021 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11021918A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.