Provider Demographics
NPI:1881005478
Name:ODETALLA, FATIMA (DNP, FNP/PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:FATIMA
Middle Name:
Last Name:ODETALLA
Suffix:
Gender:F
Credentials:DNP, FNP/PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 E MALTBIE AVE
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-6007
Mailing Address - Country:US
Mailing Address - Phone:901-590-7680
Mailing Address - Fax:
Practice Address - Street 1:65 E MALTBIE AVE
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-6007
Practice Address - Country:US
Practice Address - Phone:901-590-7680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF338723363LF0000X
TN18374363LF0000X, 363LP0808X
NYF401694363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily