Provider Demographics
NPI:1528556818
Name:O'DANIEL, CAROLYN MARIE
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:MARIE
Last Name:O'DANIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:MARIE
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-0284
Mailing Address - Country:US
Mailing Address - Phone:405-326-9673
Mailing Address - Fax:
Practice Address - Street 1:1044 SW 44TH ST STE 350
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3625
Practice Address - Country:US
Practice Address - Phone:405-631-3085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156F00000X, 2472E0500X
NA2472E0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG
No156F00000XEye and Vision Services ProvidersTechnician/Technologist