Provider Demographics
NPI:1578045597
Name:O'DONNELL, HEATHER LESLEY
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LESLEY
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 364
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:NY
Mailing Address - Zip Code:12525-0364
Mailing Address - Country:US
Mailing Address - Phone:845-633-8806
Mailing Address - Fax:
Practice Address - Street 1:129 STELLA DR
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:NY
Practice Address - Zip Code:12525-5418
Practice Address - Country:US
Practice Address - Phone:917-972-9646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY793462174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist