Provider Demographics
NPI:1073122917
Name:ODOM, NICOLE L (MSN, APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:ODOM
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2454 E AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:GIDDINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78942-3636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2454 E AUSTIN ST
Practice Address - Street 2:
Practice Address - City:GIDDINGS
Practice Address - State:TX
Practice Address - Zip Code:78942-3636
Practice Address - Country:US
Practice Address - Phone:979-542-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143392363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily