Provider Demographics
NPI:1689495939
Name:ODOM, TAVONDA MARSHEA
Entity type:Individual
Prefix:
First Name:TAVONDA
Middle Name:MARSHEA
Last Name:ODOM
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 1:706 PARK ST APT D
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4541
Mailing Address - Country:US
Mailing Address - Phone:701-578-6761
Mailing Address - Fax:
Practice Address - Street 1:706 PARK ST APT D
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4541
Practice Address - Country:US
Practice Address - Phone:701-578-6761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND101895374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide