Healthcare Provider Details

I. General information

NPI: 1376243022
Provider Name (Legal Business Name): CASEY JO ODOM FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13575 HEATHCOTE BLVD STE 210
GAINESVILLE VA
20155-6698
US

IV. Provider business mailing address

PO BOX 37189
BALTIMORE MD
21297-3189
US

V. Phone/Fax

Practice location:
  • Phone: 571-248-4620
  • Fax: 571-248-4374
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024186849
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: