Provider Demographics
NPI:1710512744
Name:ODIE, LOLITA ALANNA
Entity Type:Individual
Prefix:
First Name:LOLITA
Middle Name:ALANNA
Last Name:ODIE
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 734812
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4812
Mailing Address - Country:US
Mailing Address - Phone:210-358-9500
Mailing Address - Fax:210-358-9183
Practice Address - Street 1:4647 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4403
Practice Address - Country:US
Practice Address - Phone:210-358-5510
Practice Address - Fax:210-358-8536
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142785363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner