Provider Demographics
NPI:1699572289
Name:MAITLAND, ODEISHA M (FNP)
Entity type:Individual
Prefix:
First Name:ODEISHA
Middle Name:M
Last Name:MAITLAND
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11416 194TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2731
Mailing Address - Country:US
Mailing Address - Phone:347-645-5874
Mailing Address - Fax:
Practice Address - Street 1:11416 194TH ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2731
Practice Address - Country:US
Practice Address - Phone:347-645-5874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-28
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY356242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily