Provider Demographics
NPI:1962979252
Name:ODLE, CARMALENE (RN, BSN)
Entity type:Individual
Prefix:
First Name:CARMALENE
Middle Name:
Last Name:ODLE
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:CARMALENE
Other - Middle Name:ODLE
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:PO BOX 120
Mailing Address - Street 2:
Mailing Address - City:WESTCLIFFE
Mailing Address - State:CO
Mailing Address - Zip Code:81252-0120
Mailing Address - Country:US
Mailing Address - Phone:719-783-3369
Mailing Address - Fax:
Practice Address - Street 1:704 EDWARDS AVE
Practice Address - Street 2:
Practice Address - City:WESTCLIFFE
Practice Address - State:CO
Practice Address - Zip Code:81252-8588
Practice Address - Country:US
Practice Address - Phone:719-783-3369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1620983163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1528583291Medicaid