Basic Information
| Provider Information | |||||||||
| NPI: | 1740526649 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ODOM | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | RE'NAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP-BC, FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 13500 SUTTON PARK DRIVE SOUTH | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322245291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044933390 | ||||||||
| FaxNumber: | 9044933395 | ||||||||
| Practice Location | |||||||||
| Address1: | 13500 SUTTON PARK DRIVE SOUTH | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322245291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044933390 | ||||||||
| FaxNumber: | 9044933395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2012 | ||||||||
| LastUpdateDate: | 04/10/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9190635 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 45681 | 01 | FL | MEDICARE - GROUP | OTHER | Y0FX6 | 01 | FL | FLORIDA BLUE | OTHER | GW733Y | 01 | FL | MEDICARE - INDIVIDUAL | OTHER |