Provider Demographics
NPI:1689210510
Name:O'DELL, LISA L
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:O'DELL
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 1:1231 FIGUEROA ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2136
Mailing Address - Country:US
Mailing Address - Phone:509-301-8039
Mailing Address - Fax:
Practice Address - Street 1:77 WAINWRIGHT DR
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3975
Practice Address - Country:US
Practice Address - Phone:509-525-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60761720163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse