Basic Information
| Provider Information | |||||||||
| NPI: | 1710512744 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODIE | ||||||||
| FirstName: | LOLITA | ||||||||
| MiddleName: | ALANNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 734812 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753734812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103589500 | ||||||||
| FaxNumber: | 2103589183 | ||||||||
| Practice Location | |||||||||
| Address1: | 4647 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103585510 | ||||||||
| FaxNumber: | 2103588536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2020 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP142785 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | AP142785 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.