Healthcare Provider Details

I. General information

NPI: 1205693942
Provider Name (Legal Business Name): BRANDY ROSE-CHARLENE WILSON-ODOM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 02/29/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 NATIONWIDE DR
LYNCHBURG VA
24502-4272
US

IV. Provider business mailing address

615 BAY HILL DR APT 6
TRAVERSE CITY MI
49684-5644
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-3908
  • Fax:
Mailing address:
  • Phone: 231-357-1764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009901
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: