Provider Demographics
NPI:1093798266
Name:ODOM, CYNTHIA C (CNM, FNP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:C
Last Name:ODOM
Suffix:
Gender:F
Credentials:CNM, FNP
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:C
Other - Last Name:LOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM, FNP
Mailing Address - Street 1:PO BOX 1249
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:MS
Mailing Address - Zip Code:39367-1249
Mailing Address - Country:US
Mailing Address - Phone:601-735-2401
Mailing Address - Fax:601-735-5205
Practice Address - Street 1:920 MATTHEW DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2553
Practice Address - Country:US
Practice Address - Phone:601-735-2401
Practice Address - Fax:601-735-5205
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR748528367A00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL730-19137OtherBCBS OF AL
MS00116409Medicaid
AL569900143Medicaid
MS512I420006Medicare PIN
AL730-19137OtherBCBS OF AL
AL730-19137OtherBCBS OF AL