Provider Demographics
NPI:1811977846
Name:ODENDAHL, KEITH WAYNE (NP)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:WAYNE
Last Name:ODENDAHL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BURTON HILLS BLVD
Mailing Address - Street 2:STE 175
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6403
Mailing Address - Country:US
Mailing Address - Phone:615-988-2014
Mailing Address - Fax:615-864-7565
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE1000
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-767-3900
Practice Address - Fax:225-214-9109
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03719363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00712670OtherRAILROAD MCARE THRU PEPA
LA1431940Medicaid
LA310063OtherWELLCARE
LA1431940Medicaid
LA310063OtherWELLCARE
LAP00712670OtherRAILROAD MCARE THRU PEPA