Provider Demographics
NPI:1750863726
Name:ODOM, AMY REBECCA (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:REBECCA
Last Name:ODOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7987
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36670-0987
Mailing Address - Country:US
Mailing Address - Phone:251-633-0573
Mailing Address - Fax:
Practice Address - Street 1:5955 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3135
Practice Address - Country:US
Practice Address - Phone:251-633-0573
Practice Address - Fax:251-633-7367
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-140750363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL224261Medicaid
AL512-17406OtherBCBS OF AL
ALA03845AOtherMEDICARE
AL225622Medicaid
AL512-17405OtherBCBS OF AL
AL630799312OtherHUMANA CHOICECARE
ALZ54984OtherVIVA HEALTH
AL6297709OtherAETNA
ALP02140037OtherRR MEDICARE
MS05331824Medicaid
AL223807Medicaid
AL225017Medicaid
AL225084Medicaid
AL512-17400OtherBCBS OF AL
AL512-17403OtherBCBS OF AL
AL512-17404OtherBCBS OF AL
AL6906123OtherUNITED HEALTHCARE