Provider Demographics
NPI:1588365142
Name:ODEM, ALONZO J
Entity type:Individual
Prefix:
First Name:ALONZO
Middle Name:J
Last Name:ODEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 MISTY LN
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98674-3238
Mailing Address - Country:US
Mailing Address - Phone:712-463-3181
Mailing Address - Fax:
Practice Address - Street 1:211 MISTY LN
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:WA
Practice Address - Zip Code:98674-3238
Practice Address - Country:US
Practice Address - Phone:712-463-3181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60557638163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse