Healthcare Provider Details

I. General information

NPI: 1043940141
Provider Name (Legal Business Name): CHRISTINA ANNA NICOLE ODOM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 12/21/2025
Certification Date: 12/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 CARNEGIE PL STE 106
FAYETTEVILLE GA
30214-3980
US

IV. Provider business mailing address

7580 DEERRIDGE WAY
FAIRBURN GA
30213-6556
US

V. Phone/Fax

Practice location:
  • Phone: 770-716-7999
  • Fax: 770-716-8444
Mailing address:
  • Phone: 678-763-4919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN275604
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: