Provider Demographics
NPI:1417696568
Name:ODLE, PHILLIP RAY (MSN, RN-BC)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:RAY
Last Name:ODLE
Suffix:
Gender:M
Credentials:MSN, RN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 EDGEWOOD PARK
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5513
Mailing Address - Country:US
Mailing Address - Phone:618-889-0031
Mailing Address - Fax:
Practice Address - Street 1:3007 EDGEWOOD PARK
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5513
Practice Address - Country:US
Practice Address - Phone:618-889-0031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.401540163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041.401540OtherREGISTERED NURSE LICENSE
MD2011010604OtherAMERICAN NURSES CREDENTIALING CENTER - NURSING INFORMATICS BOARD CERTIFICATION