Healthcare Provider Details

I. General information

NPI: 1033364716
Provider Name (Legal Business Name): TERESSA GAYLE O'DANIEL 03/07/2007
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1093 NARROW GAUGE CT
WINTER GARDEN FL
34787-2124
US

IV. Provider business mailing address

1093 NARROW GAUGE CT
WINTER GARDEN FL
34787-2124
US

V. Phone/Fax

Practice location:
  • Phone: 407-656-0362
  • Fax:
Mailing address:
  • Phone: 407-656-0362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberOTA5830
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: