Provider Demographics
NPI:1447937792
Name:ODIGIE, GODWINA PAMELA
Entity type:Individual
Prefix:
First Name:GODWINA
Middle Name:PAMELA
Last Name:ODIGIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP-PMH
Mailing Address - Street 1:9331 LIBERTY RD STE 2A9331
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-3525
Mailing Address - Country:US
Mailing Address - Phone:443-982-3052
Mailing Address - Fax:
Practice Address - Street 1:9331 LIBERTY RD STE 2A9331
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-3525
Practice Address - Country:US
Practice Address - Phone:443-982-3052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR158859363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health