Provider Demographics
NPI:1043212236
Name:ODOM, ANNA (NP)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 VERNON RD
Mailing Address - Street 2:STE 400
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4100
Mailing Address - Country:US
Mailing Address - Phone:706-882-9341
Mailing Address - Fax:706-884-0131
Practice Address - Street 1:1602 VERNON RD
Practice Address - Street 2:STE 400
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4100
Practice Address - Country:US
Practice Address - Phone:706-882-9341
Practice Address - Fax:706-884-0131
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113102 NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBGRMMedicare ID - Type Unspecified
GAP14218Medicare UPIN