Provider Demographics
NPI:1396009858
Name:O'DONNELL, THERESA R (APNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:R
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:R
Other - Last Name:MAYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:320 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-2931
Mailing Address - Country:US
Mailing Address - Phone:305-799-7669
Mailing Address - Fax:
Practice Address - Street 1:10800 KNIGHTS RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-4200
Practice Address - Country:US
Practice Address - Phone:215-612-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9306821363LF0000X
WI7146363LF0000X
PASP014731363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily