Healthcare Provider Details

I. General information

NPI: 1134367022
Provider Name (Legal Business Name): RITA MARGARET ODOM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 01/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BRADEN ST
JACKSONVILLE AR
72076-3721
US

IV. Provider business mailing address

200 CORPORATE BLVD SUITE 201
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 800-893-9698
  • Fax:
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberP00175
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: