Provider Demographics
NPI:1043827900
Name:ODOM, CARLA
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:
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 1:107 BALL AVE
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-2101
Mailing Address - Country:US
Mailing Address - Phone:601-377-1975
Mailing Address - Fax:
Practice Address - Street 1:963 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:MS
Practice Address - Zip Code:39643-4967
Practice Address - Country:US
Practice Address - Phone:601-303-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904705363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily