1336824689 NPI number — SHELLEY DENISE O'DELL-BROCK DAC

Table of content: SHELLEY DENISE O'DELL-BROCK DAC (NPI 1336824689)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336824689 NPI number — SHELLEY DENISE O'DELL-BROCK DAC

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
O'DELL-BROCK

Provider First Name:
SHELLEY

Provider Middle Name:
DENISE

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
DAC

Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:
O'DELL

Provider Other First Name:
SHELLEY

Provider Other Middle Name:
DENISE

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1336824689

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
06/15/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
335 W WESCOTT DR

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
PHOENIX

Provider Business Mailing Address State Name:
AZ

Provider Business Mailing Address Postal Code:
85027-5626

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
602-697-1962

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4611 E SHEA BLVD STE 180

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
PHOENIX

Provider Business Practice Location Address State Name:
AZ

Provider Business Practice Location Address Postal Code:
85028-4258

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
602-697-1962

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
06/15/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 171100000X , with the licence number: LAC-000936 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .