Provider Demographics
NPI:1477755908
Name:PATTERSON-O'DELL, MADELINE (RD)
Entity Type:Individual
Prefix:MS
First Name:MADELINE
Middle Name:
Last Name:PATTERSON-O'DELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 BLACKBERRY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99712-1810
Mailing Address - Country:US
Mailing Address - Phone:303-520-8975
Mailing Address - Fax:
Practice Address - Street 1:1400 BLACKBERRY DR
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99712-1810
Practice Address - Country:US
Practice Address - Phone:303-520-8975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133VN1005X, 133NN1002X, 133VN1006X, 133VN1101X, 133VN1201X
AK163133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133VN1101XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Gerontological
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDT7897Medicaid