Provider Demographics
NPI:1750318309
Name:O'DONNELL, REGINA THERESA (FNP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:THERESA
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 CAROLINA BEACH AVE N
Mailing Address - Street 2:UNIT 1A
Mailing Address - City:CAROLINA BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28428-6091
Mailing Address - Country:US
Mailing Address - Phone:607-229-5861
Mailing Address - Fax:
Practice Address - Street 1:2222 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7515
Practice Address - Country:US
Practice Address - Phone:910-622-7491
Practice Address - Fax:910-796-7901
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY110078163WH1000X
NC227328363LF0000X
NY327382363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH1000XNursing Service ProvidersRegistered NurseHospice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01380583Medicaid