Provider Demographics
NPI:1295216760
Name:ODOM, REGINA (LVN)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 MEADOWLANE ST APT A
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-7552
Mailing Address - Country:US
Mailing Address - Phone:361-655-1393
Mailing Address - Fax:
Practice Address - Street 1:2058 BERGER RD
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77905-5208
Practice Address - Country:US
Practice Address - Phone:361-655-1393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX316484164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse