Provider Demographics
NPI:1396202479
Name:GEORGE ODUTAYO, RACHAEL M (NP)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:M
Last Name:GEORGE ODUTAYO
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 1:310 AMERICAN WAY STE A
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-4083
Mailing Address - Country:US
Mailing Address - Phone:843-206-2031
Mailing Address - Fax:
Practice Address - Street 1:310 AMERICAN WAY STE A
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-4083
Practice Address - Country:US
Practice Address - Phone:304-797-6410
Practice Address - Fax:304-797-6320
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV103156363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC22656OtherSOUTH CAROLINA BOARD OF NURSING