Provider Demographics
NPI:1740519602
Name:ODAMS, CHANNIE LATAURUS (LPN)
Entity type:Individual
Prefix:
First Name:CHANNIE
Middle Name:LATAURUS
Last Name:ODAMS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 SUMPTER ROAD
Mailing Address - Street 2:#436
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111
Mailing Address - Country:US
Mailing Address - Phone:734-851-1577
Mailing Address - Fax:
Practice Address - Street 1:40075 EATON ST APT 203
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-4526
Practice Address - Country:US
Practice Address - Phone:734-521-1577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC71594164W00000X
GALPN090950164W00000X
MI171M00000X, 172A00000X, 374700000X, 3747P1801X, 376J00000X
372500000X, 372600000X, 374U00000X, 376K00000X
MI3747A0650X3747A0650X
MI4703101060164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No374700000XNursing Service Related ProvidersTechnician
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI81-1703832OtherEIN