Provider Demographics
NPI:1861900607
Name:ODEK, IMMACULATE ADHIAMBO (CRNP)
Entity type:Individual
Prefix:
First Name:IMMACULATE
Middle Name:ADHIAMBO
Last Name:ODEK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8601 MANCHESTER RD APT 505
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-6194
Mailing Address - Country:US
Mailing Address - Phone:202-517-3038
Mailing Address - Fax:
Practice Address - Street 1:8601 MANCHESTER RD APT 505
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-6194
Practice Address - Country:US
Practice Address - Phone:202-517-3038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-15
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR150668363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily