Provider Demographics
NPI:1043844202
Name:ODOM, ANNIE D
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:D
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 RAYMOND DIEHL RD APT 2
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-3628
Mailing Address - Country:US
Mailing Address - Phone:850-692-4300
Mailing Address - Fax:850-668-8329
Practice Address - Street 1:2257 CLARA KEE BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-7135
Practice Address - Country:US
Practice Address - Phone:850-405-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1155673747P1801X, 374U00000X
FL235755376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012409200Medicaid
FL39970618Medicaid
FL115567Medicaid