Provider Demographics
NPI:1033364716
Name:O'DANIEL, TERESSA GAYLE (03/07/2007)
Entity Type:Individual
Prefix:
First Name:TERESSA
Middle Name:GAYLE
Last Name:O'DANIEL
Suffix:
Gender:F
Credentials:03/07/2007
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1093 NARROW GAUGE CT
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-2124
Mailing Address - Country:US
Mailing Address - Phone:407-656-0362
Mailing Address - Fax:
Practice Address - Street 1:1093 NARROW GAUGE CT
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-2124
Practice Address - Country:US
Practice Address - Phone:407-656-0362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA5830247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other