Provider Demographics
NPI:1124604988
Name:ODIMMA, KELECHI (APN)
Entity Type:Individual
Prefix:
First Name:KELECHI
Middle Name:
Last Name:ODIMMA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:KELECHI
Other - Middle Name:
Other - Last Name:ODIMMA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APN
Mailing Address - Street 1:7 JADE LN
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-7325
Mailing Address - Country:US
Mailing Address - Phone:973-668-3872
Mailing Address - Fax:
Practice Address - Street 1:7 JADE LN
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-7325
Practice Address - Country:US
Practice Address - Phone:973-668-3872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01475500363LP0808X
NJ26NR14318700163W00000X
NJ2022030241363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse