Healthcare Provider Details

I. General information

NPI: 1780338269
Provider Name (Legal Business Name): MRS. HAKYOUNG ELIZABETH ODOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 02/04/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5356 REYNOLDS ST
SAVANNAH GA
31405-6016
US

IV. Provider business mailing address

5356 REYNOLDS ST
SAVANNAH GA
31405-6016
US

V. Phone/Fax

Practice location:
  • Phone: 912-819-8141
  • Fax: 912-819-6161
Mailing address:
  • Phone: 912-819-8141
  • Fax: 912-819-6161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN274980
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: