Provider Demographics
NPI:1154068096
Name:ODELUS, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:ODELUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11138 STATE BRIDGE RD # 100A
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-7465
Mailing Address - Country:US
Mailing Address - Phone:866-987-3575
Mailing Address - Fax:
Practice Address - Street 1:11138 STATE BRIDGE RD # 100A
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-7465
Practice Address - Country:US
Practice Address - Phone:866-987-3575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA262562363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health