Provider Demographics
NPI:1922652049
Name:ODOM, ROXIAN H (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:ROXIAN
Middle Name:H
Last Name:ODOM
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 TURKEY HOLW
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170-9104
Mailing Address - Country:US
Mailing Address - Phone:601-618-6000
Mailing Address - Fax:
Practice Address - Street 1:1776 HIGHWAY 49 S
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-9429
Practice Address - Country:US
Practice Address - Phone:601-825-6010
Practice Address - Fax:601-825-7146
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903462363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07230211Medicaid