Provider Demographics
NPI:1851588602
Name:ODURO MANU, GLADYS AMMA (CNP)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:AMMA
Last Name:ODURO MANU
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-1002
Mailing Address - Country:US
Mailing Address - Phone:614-645-2700
Mailing Address - Fax:614-645-2727
Practice Address - Street 1:1500 E 17TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-1002
Practice Address - Country:US
Practice Address - Phone:614-645-2700
Practice Address - Fax:614-645-2727
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRX.14854-EX1363LF0000X
OHRN.317610-COA1363LF0000X
OHCOA.14854-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH228343Medicare PIN
OHH228340Medicare PIN
OHH228344Medicare PIN
OHH228341Medicare PIN
OHH228345Medicare PIN
OHH228342Medicare PIN