Provider Demographics
NPI:1669933370
Name:ODOM, SANDRA ELAINE
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:ELAINE
Last Name:ODOM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:PATTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:11 HIGHWAY 247
Mailing Address - Street 2:
Mailing Address - City:CASA
Mailing Address - State:AR
Mailing Address - Zip Code:72025-9700
Mailing Address - Country:US
Mailing Address - Phone:479-330-0159
Mailing Address - Fax:
Practice Address - Street 1:11 HIGHWAY 247
Practice Address - Street 2:
Practice Address - City:CASA
Practice Address - State:AR
Practice Address - Zip Code:72025-9700
Practice Address - Country:US
Practice Address - Phone:479-330-0159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA006138363L00000X, 363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care