Provider Demographics
NPI:1538635297
Name:O'DONNELL, JENNIFER LEA NICOLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEA NICOLE
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13861 MANCHESTER ROAD
Mailing Address - Street 2:
Mailing Address - City:TOWN AND COUNTRY
Mailing Address - State:MO
Mailing Address - Zip Code:63011
Mailing Address - Country:US
Mailing Address - Phone:636-556-0114
Mailing Address - Fax:314-270-3694
Practice Address - Street 1:13861 MANCHESTER ROAD
Practice Address - Street 2:
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63011
Practice Address - Country:US
Practice Address - Phone:636-556-0114
Practice Address - Fax:314-270-3694
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010028309163W00000X
MO2018040236363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse