Provider Demographics
NPI:1366622961
Name:O'DELL, STEPHANIE M (NP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:M
Last Name:O'DELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10625 W NORTH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2315
Mailing Address - Country:US
Mailing Address - Phone:414-877-5350
Mailing Address - Fax:414-877-5360
Practice Address - Street 1:10625 W NORTH AVE STE 102
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-2315
Practice Address - Country:US
Practice Address - Phone:414-877-5350
Practice Address - Fax:414-877-5360
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131693363L00000X, 363L00000X
WI3315-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI331503333334OtherBLUE SHIELD
WI36052500Medicaid
WI331503300004OtherBLUE SHIELD
WI007401473Medicare PIN
WI331503333334OtherBLUE SHIELD