Provider Demographics
NPI:1588673818
Name:O'DEA, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:O'DEA
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 1:525 PORTLAND AVE
Mailing Address - Street 2:MC: 952
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1533
Mailing Address - Country:US
Mailing Address - Phone:612-348-9840
Mailing Address - Fax:612-596-7900
Practice Address - Street 1:525 PORTLAND AVE
Practice Address - Street 2:MC: 952
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1533
Practice Address - Country:US
Practice Address - Phone:612-348-9840
Practice Address - Fax:612-596-7900
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 062385-6363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6982979OtherEVERCARE
MNHP21019OtherHEALTHPARTNERS
MN1200207OtherMEDICA
MN718015200Medicaid
MNHP21019OtherHEALTHPARTNERS