Provider Demographics
NPI:1306437355
Name:ALENI-ODEH, SHELLEY
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:ALENI-ODEH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2832 N CAMINO LAGOS
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-6755
Mailing Address - Country:US
Mailing Address - Phone:205-862-8790
Mailing Address - Fax:
Practice Address - Street 1:2832 N CAMINO LAGOS
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75054-6755
Practice Address - Country:US
Practice Address - Phone:205-862-8790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX861788362Medicaid