Provider Demographics
NPI:1548610959
Name:ODESINA, CARLY M (APRN)
Entity Type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:M
Last Name:ODESINA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4820
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:270 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:CT
Practice Address - Zip Code:06480-1836
Practice Address - Country:US
Practice Address - Phone:860-342-3392
Practice Address - Fax:860-358-8658
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.006642363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008067661Medicaid
CTD400322787Medicare PIN