Basic Information
| Provider Information | |||||||||
| NPI: | 1053385211 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODELL | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | NANCY | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PAC CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 SW 4TH AVENUE | ||||||||
| Address2: | #1500 | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544626793 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8399 W OAKLAND PARK BOULEVARD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547414181 | ||||||||
| FaxNumber: | 9547468699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 09/03/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9101438 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.