Provider Demographics
NPI:1841572922
Name:ODUM, KELLY DIANE (FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:ODUM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 WALLACE RD
Mailing Address - Street 2:BUILDING C, SUITE 100
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-4854
Mailing Address - Country:US
Mailing Address - Phone:615-834-6166
Mailing Address - Fax:
Practice Address - Street 1:397 WALLACE RD
Practice Address - Street 2:BUILDING C, SUITE 100
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-4854
Practice Address - Country:US
Practice Address - Phone:615-834-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16109363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily