Provider Demographics
NPI:1043940141
Name:ODOM, CHRISTINA ANNA NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ANNA NICOLE
Last Name:ODOM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7580 DEERRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-6556
Mailing Address - Country:US
Mailing Address - Phone:678-763-4919
Mailing Address - Fax:
Practice Address - Street 1:105 CARNEGIE PL STE 106
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-3980
Practice Address - Country:US
Practice Address - Phone:770-716-7999
Practice Address - Fax:770-716-8444
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN275604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily