Provider Demographics
NPI:1093316820
Name:LACOSSIERE-DORVILUS, ODYNE ROSE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:ODYNE
Middle Name:ROSE
Last Name:LACOSSIERE-DORVILUS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 CENTER STREET
Mailing Address - Street 2:SC HOUSE CALLS INC
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169
Mailing Address - Country:US
Mailing Address - Phone:800-491-0909
Mailing Address - Fax:
Practice Address - Street 1:1053 CENTER STREET
Practice Address - Street 2:SC HOUSE CALLS INC
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169
Practice Address - Country:US
Practice Address - Phone:800-491-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA192699363LF0000X
SC24775363LF0000X
GARN192699363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily