Provider Demographics
NPI:1245241272
Name:GALLETT, ODESSA M (RDCD)
Entity Type:Individual
Prefix:
First Name:ODESSA
Middle Name:M
Last Name:GALLETT
Suffix:
Gender:F
Credentials:RDCD
Other - Prefix:
Other - First Name:ODESSA
Other - Middle Name:M
Other - Last Name:SYRYCZUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RCDC
Mailing Address - Street 1:143 SOUTH GIBSON STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1622
Mailing Address - Country:US
Mailing Address - Phone:715-748-2121
Mailing Address - Fax:
Practice Address - Street 1:143 SOUTH GIBSON STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1622
Practice Address - Country:US
Practice Address - Phone:715-748-2121
Practice Address - Fax:715-748-7590
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1752133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100531OtherSECURITY HEALTH PLAN
WI004161030Medicare ID - Type Unspecified