Provider Demographics
NPI:1073680633
Name:ODELL, NICCOLE MARIE
Entity type:Individual
Prefix:
First Name:NICCOLE
Middle Name:MARIE
Last Name:ODELL
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 1:9988 HIBERT ST STE 206
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-2480
Mailing Address - Country:US
Mailing Address - Phone:858-736-5387
Mailing Address - Fax:858-935-9104
Practice Address - Street 1:9988 HIBERT ST STE 206
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-2480
Practice Address - Country:US
Practice Address - Phone:858-736-5387
Practice Address - Fax:858-635-9104
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32183111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor