Provider Demographics
NPI:1336351634
Name:ODOM-MACK, SHALANDA M
Entity type:Individual
Prefix:MRS
First Name:SHALANDA
Middle Name:M
Last Name:ODOM-MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SHALANDA
Other - Middle Name:M
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11305 KEPPLER CT
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-6242
Mailing Address - Country:US
Mailing Address - Phone:216-331-1321
Mailing Address - Fax:216-331-1321
Practice Address - Street 1:11305 KEPPLER CT
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-6242
Practice Address - Country:US
Practice Address - Phone:216-801-2700
Practice Address - Fax:216-801-2700
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376939251197376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2365435Medicaid