Provider Demographics
NPI:1619551900
Name:ODOM, ASHLEY (RN)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12932 HAZELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NOKESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20181-2505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12932 HAZELWOOD DR
Practice Address - Street 2:
Practice Address - City:NOKESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20181-2505
Practice Address - Country:US
Practice Address - Phone:540-392-8021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61140546163W00000X, 163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0000000Medicaid
VA00000000OtherN/A