Provider Demographics
NPI:1659882348
Name:ODOM, AMY COVINGTON
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:COVINGTON
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4040
Mailing Address - Country:US
Mailing Address - Phone:601-703-3480
Mailing Address - Fax:601-703-0124
Practice Address - Street 1:2124 14TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4040
Practice Address - Country:US
Practice Address - Phone:601-553-6650
Practice Address - Fax:601-703-0124
Is Sole Proprietor?:No
Enumeration Date:2017-10-20
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS593516163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant