Provider Demographics
NPI:1629385463
Name:ODOM, LAURA GRADDICK (APRN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:GRADDICK
Last Name:ODOM
Suffix:
Gender:F
Credentials: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 1:1109 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-3443
Mailing Address - Country:US
Mailing Address - Phone:803-321-3035
Mailing Address - Fax:803-321-3034
Practice Address - Street 1:1109 WILSON ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-3443
Practice Address - Country:US
Practice Address - Phone:803-321-3035
Practice Address - Fax:803-321-3034
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2014-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4256363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily