Provider Demographics
NPI:1073880621
Name:ODHNER, MARIKO LEE
Entity Type:Individual
Prefix:
First Name:MARIKO
Middle Name:LEE
Last Name:ODHNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIKO
Other - Middle Name:LEE
Other - Last Name:JAMESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6152
Mailing Address - Country:US
Mailing Address - Phone:617-519-8246
Mailing Address - Fax:
Practice Address - Street 1:269 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1314
Practice Address - Country:US
Practice Address - Phone:781-596-2502
Practice Address - Fax:781-596-3966
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINP37010363LF0000X
MA2268187363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily