Provider Demographics
NPI:1629437660
Name:O'DONNELL, MAUREEN
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:O'DONNELL
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 1:600 JEFFERSON ST STE 600
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-6987
Mailing Address - Country:US
Mailing Address - Phone:337-202-0720
Mailing Address - Fax:337-465-4604
Practice Address - Street 1:971 ROBERT BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2009
Practice Address - Country:US
Practice Address - Phone:985-690-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058115363A00000X
LA340826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant