Healthcare Provider Details

I. General information

NPI: 1093798266
Provider Name (Legal Business Name): CYNTHIA C. ODOM CNM, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CYNTHIA C. LOPER CNM, FNP

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 MATTHEW DR
WAYNESBORO MS
39367-2553
US

IV. Provider business mailing address

PO BOX 1249
WAYNESBORO MS
39367-1249
US

V. Phone/Fax

Practice location:
  • Phone: 601-735-2401
  • Fax: 601-735-5205
Mailing address:
  • Phone: 601-735-2401
  • Fax: 601-735-5205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberR748528
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR748528
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: