Provider Demographics
NPI:1578074647
Name:ODOM, NICOLE E (NP-C)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:E
Last Name:ODOM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:248-577-3313
Mailing Address - Fax:248-577-3302
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-0633
Practice Address - Fax:248-898-3393
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704296896363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner