Healthcare Provider Details

I. General information

NPI: 1124598677
Provider Name (Legal Business Name): SKYLER SHANELLE O'DELL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9041 EXECUTIVE PARK DR STE 118
KNOXVILLE TN
37923-4603
US

IV. Provider business mailing address

9041 EXECUTIVE PARK DR STE 118
KNOXVILLE TN
37923-4603
US

V. Phone/Fax

Practice location:
  • Phone: 865-399-2055
  • Fax:
Mailing address:
  • Phone: 865-399-2055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number12589
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: