Provider Demographics
NPI:1740823434
Name:ODIGIE, GLORY EKELEOSEYE
Entity type:Individual
Prefix:
First Name:GLORY
Middle Name:EKELEOSEYE
Last Name:ODIGIE
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 1:8011 RIVER GATE LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-3328
Mailing Address - Country:US
Mailing Address - Phone:240-704-3271
Mailing Address - Fax:
Practice Address - Street 1:157 BALTIMORE ST STE 100
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2472
Practice Address - Country:US
Practice Address - Phone:301-722-0484
Practice Address - Fax:833-903-0130
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR215670363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner