Provider Demographics
NPI:1962856179
Name:BREW, ODELIA
Entity Type:Individual
Prefix:
First Name:ODELIA
Middle Name:
Last Name:BREW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ODELIA
Other - Middle Name:
Other - Last Name:BAAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, NP-C
Mailing Address - Street 1:256 HACKMATACK ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-6514
Mailing Address - Country:US
Mailing Address - Phone:404-667-6011
Mailing Address - Fax:860-792-8004
Practice Address - Street 1:256 HACKMATACK STREET
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040
Practice Address - Country:US
Practice Address - Phone:404-667-6011
Practice Address - Fax:860-792-8004
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.006638363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care