Provider Demographics
NPI:1376020420
Name:O'DELL, AUDRA AGENT (APRN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:AUDRA
Middle Name:AGENT
Last Name:O'DELL
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S WHEELER AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-6225
Mailing Address - Country:US
Mailing Address - Phone:918-315-1768
Mailing Address - Fax:
Practice Address - Street 1:1109 E CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-5035
Practice Address - Country:US
Practice Address - Phone:918-790-3309
Practice Address - Fax:918-775-0587
Is Sole Proprietor?:No
Enumeration Date:2018-07-22
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK114565363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200782520AMedicaid