Healthcare Provider Details

I. General information

NPI: 1508643974
Provider Name (Legal Business Name): MANDY LEE ODOM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 N KELSEY ST
STURGIS KY
42459-1434
US

IV. Provider business mailing address

711 N KELSEY ST
STURGIS KY
42459-1434
US

V. Phone/Fax

Practice location:
  • Phone: 270-952-5653
  • Fax:
Mailing address:
  • Phone: 270-952-5653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3018830
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: