Provider Demographics
NPI:1689665374
Name:HORNSBY-ODOM, MISTY GAYLENE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:GAYLENE
Last Name:HORNSBY-ODOM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 THOROUGHBRED
Mailing Address - Street 2:
Mailing Address - City:FATE
Mailing Address - State:TX
Mailing Address - Zip Code:75087-6863
Mailing Address - Country:US
Mailing Address - Phone:469-323-0332
Mailing Address - Fax:
Practice Address - Street 1:2306 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-5140
Practice Address - Country:US
Practice Address - Phone:972-771-8316
Practice Address - Fax:972-722-9214
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX606499363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B8668Medicare ID - Type Unspecified
Q15699Medicare UPIN