Healthcare Provider Details

I. General information

NPI: 1033882113
Provider Name (Legal Business Name): NICOLE MICHELLE ODOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date: 10/13/2025
Reactivation Date: 10/30/2025

III. Provider practice location address

108 FREDERICK DR
LIVERPOOL NY
13088-6205
US

IV. Provider business mailing address

108 FREDERICK DR
LIVERPOOL NY
13088-6205
US

V. Phone/Fax

Practice location:
  • Phone: 315-383-2416
  • Fax:
Mailing address:
  • Phone: 315-383-2416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: