Provider Demographics
NPI:1386440857
Name:ODOM, TATIANA L
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:L
Last Name:ODOM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 SW RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-7126
Mailing Address - Country:US
Mailing Address - Phone:402-417-6572
Mailing Address - Fax:
Practice Address - Street 1:308 SW RIDGE LN
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-7126
Practice Address - Country:US
Practice Address - Phone:402-417-6572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-24
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter