Provider Demographics
NPI:1598007668
Name:ODOM, LISA NICOLE
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:NICOLE
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POB 31001-4114
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-4114
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-944-9644
Practice Address - Street 1:16528 E DESMET CT STE B1000
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-3522
Practice Address - Country:US
Practice Address - Phone:509-944-8770
Practice Address - Fax:509-944-8856
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13382208000000X
WAMD70024994208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics