Provider Demographics
NPI:1912710112
Name:ODOM, TEAGAN J
Entity type:Individual
Prefix:MISS
First Name:TEAGAN
Middle Name:J
Last Name:ODOM
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 1:1925 CORPORATE SQUARE DR STE E
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3163
Mailing Address - Country:US
Mailing Address - Phone:985-214-9147
Mailing Address - Fax:985-214-9116
Practice Address - Street 1:1925 CORPORATE SQUARE DR STE E
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-3163
Practice Address - Country:US
Practice Address - Phone:985-214-9147
Practice Address - Fax:985-214-9116
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA000003747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty