Provider Demographics
NPI:1386644425
Name:O'DANIEL, TAMALYNN (APRN)
Entity Type:Individual
Prefix:
First Name:TAMALYNN
Middle Name:
Last Name:O'DANIEL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 CHICKADEE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1307
Mailing Address - Country:US
Mailing Address - Phone:507-400-8636
Mailing Address - Fax:516-531-8816
Practice Address - Street 1:3209 CHICKADEE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1307
Practice Address - Country:US
Practice Address - Phone:507-400-8636
Practice Address - Fax:516-531-8816
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001869A363LF0000X, 363LA2100X
KY3003327363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3003327OtherAPRN LICENSURE
KY50033116OtherPASSPORT HEALTH- NNIKY
KYK001750OtherMEDICARE PTAN-NNIKY
KY000000710707OtherANTHEM -- NNIKY
KY041611OtherSIHO- NNIKY
IN201040220OtherMEDICAID- NNIKY
KY78017282Medicaid
KY000000549731OtherANTHEM
IN200890320Medicaid
KY3431407000OtherPASSPORT ADVANTAGE
KY50017919OtherPASSPORT
KY3431407000OtherPASSPORT ADVANTAGE
P20824Medicare UPIN
KYP00631553Medicare PIN
KY000057119YOtherHUMANA -- NNIKY
KY0098616Medicare PIN