Provider Demographics
NPI:1164944633
Name:PERSON, O'DONIS J
Entity Type:Individual
Prefix:
First Name:O'DONIS
Middle Name:J
Last Name:PERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W MEM DR
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-2475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 W MEM DR
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-2475
Practice Address - Country:US
Practice Address - Phone:906-482-9404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704319068163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health