Provider Demographics
NPI:1578812145
Name:OMDAHL, TATYANA ANATOLIA
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:ANATOLIA
Last Name:OMDAHL
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 1:13920 SAGEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4228
Mailing Address - Country:US
Mailing Address - Phone:434-247-1481
Mailing Address - Fax:
Practice Address - Street 1:13920 SAGEBROOK RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4228
Practice Address - Country:US
Practice Address - Phone:434-247-1481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204078174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist