Provider Demographics
NPI:1740526649
Name:ODOM, CATHERINE RE'NAE (ARNP-BC, FNP)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:RE'NAE
Last Name:ODOM
Suffix:
Gender:F
Credentials:ARNP-BC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13500 SUTTON PARK DRIVE SOUTH
Mailing Address - Street 2:SUITE 403
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-5291
Mailing Address - Country:US
Mailing Address - Phone:904-493-3390
Mailing Address - Fax:904-493-3395
Practice Address - Street 1:13500 SUTTON PARK DRIVE SOUTH
Practice Address - Street 2:SUITE 403
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-5291
Practice Address - Country:US
Practice Address - Phone:904-493-3390
Practice Address - Fax:904-493-3395
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9190635363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45681OtherMEDICARE - GROUP
FLY0FX6OtherFLORIDA BLUE
FLGW733YOtherMEDICARE - INDIVIDUAL