Provider Demographics
NPI:1700190832
Name:ODOM, ELIZABETH BOYD (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:BOYD
Last Name:ODOM
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 NORTH DOBBS STREET
Mailing Address - Street 2:
Mailing Address - City:HALIFAX
Mailing Address - State:NC
Mailing Address - Zip Code:27839-0010
Mailing Address - Country:US
Mailing Address - Phone:252-583-5021
Mailing Address - Fax:252-583-2975
Practice Address - Street 1:19 NORTH DOBBS STREET
Practice Address - Street 2:
Practice Address - City:HALIFAX
Practice Address - State:NC
Practice Address - Zip Code:27839-0010
Practice Address - Country:US
Practice Address - Phone:252-583-5021
Practice Address - Fax:252-583-2975
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001680133N00000X
NC843319133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404433Medicaid
NC340432Medicaid
NC6005545Medicaid