Basic Information
| Provider Information | |||||||||
| NPI: | 1750863726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODOM | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | REBECCA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7987 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366700987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330573 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 MEMORIAL HOSPITAL DR STE 1A | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366081128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513436848 | ||||||||
| FaxNumber: | 2513435708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2018 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 1-140750 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LG0600X | 1-140750 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 6297709 | 01 | AL | AETNA | OTHER | 630799312 | 01 | AL | HUMANA CHOICECARE | OTHER | Z54984 | 01 | AL | VIVA HEALTH | OTHER | 225084 | 05 | AL | MEDICAID | 512-17403 | 01 | AL | BCBS OF AL | OTHER | 512-17400 | 01 | AL | BCBS OF AL | OTHER | A03845A | 01 | AL | MEDICARE | OTHER | 05331824 | 05 | MS | MEDICAID | 223807 | 05 | AL | MEDICAID | 512-17404 | 01 | AL | BCBS OF AL | OTHER | 512-17406 | 01 | AL | BCBS OF AL | OTHER | 512-17405 | 01 | AL | BCBS OF AL | OTHER | 6906123 | 01 | AL | UNITED HEALTHCARE | OTHER | 224261 | 05 | AL | MEDICAID | 225017 | 05 | AL | MEDICAID | 225622 | 05 | AL | MEDICAID | P02140037 | 01 | AL | RR MEDICARE | OTHER |