MEDICARE: EDITH HOLLIE ODOM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	25801	SC

General Provider Information

NPI Number	:	1023760626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDITH HOLLIE ODOM

Provider Business Mailing Address
First Line	:	106 LANSFORD PL # 100
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-6979
Country	:	US
Telephone Number	:	843-293-8850
Fax Number	:	843-293-8860

Provider Business Practice Location Address
First Line	:	106 LANSFORD PL # 100
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-6979
Country	:	US
Telephone Number	:	843-293-8850
Fax Number	:	843-293-8860

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2022
Last Update Date	:	01/12/2023

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Directions to “ EDITH HOLLIE ODOM ” Practice Location

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