Provider Demographics
NPI:1083688295
Name:O'DELL, STACI S (APNP)
Entity type:Individual
Prefix:MRS
First Name:STACI
Middle Name:S
Last Name:O'DELL
Suffix:
Gender:F
Credentials:APNP
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:HEALTHCARE FOR THE HOMELESS OF MILWAUKEE, INC
Mailing Address - Street 2:210 WEST CAPITOL DRIVE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212
Mailing Address - Country:US
Mailing Address - Phone:414-727-6320
Mailing Address - Fax:414-727-6321
Practice Address - Street 1:HEALTHCARE FOR THE HOMELESS OF MILWAUKEE, INC
Practice Address - Street 2:210 WEST CAPITOL DRIVE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-727-6320
Practice Address - Fax:414-727-6321
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI131460-030163WP0808X
WI3433-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0058230Medicaid
IAI16398Medicare ID - Type Unspecified