Provider Demographics
NPI:1053865956
Name:ODOM, KATHRYN FOLKNER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:FOLKNER
Last Name:ODOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:FOLKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:275 COLLIER RD NW STE 450
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1748
Mailing Address - Country:US
Mailing Address - Phone:404-351-8873
Mailing Address - Fax:404-355-6165
Practice Address - Street 1:275 COLLIER RD NW STE 450
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1748
Practice Address - Country:US
Practice Address - Phone:404-351-8873
Practice Address - Fax:404-355-6165
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007579363A00000X, 363AM0700X
GA8040363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053865956Medicaid