Provider Demographics
NPI:1013071448
Name:ODOM, RAYNELL RODGERS (NP)
Entity Type:Individual
Prefix:
First Name:RAYNELL
Middle Name:RODGERS
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 1:282 BROKEN ARROW
Mailing Address - Street 2:
Mailing Address - City:FLORESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78114-6012
Mailing Address - Country:US
Mailing Address - Phone:830-391-4050
Mailing Address - Fax:
Practice Address - Street 1:90 EAGLE CREEK RANCH BLVD
Practice Address - Street 2:
Practice Address - City:FLORESVILLE
Practice Address - State:TX
Practice Address - Zip Code:78114-9275
Practice Address - Country:US
Practice Address - Phone:830-391-0877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX502431363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12252309OtherCAQH
TX12252309OtherCAQH