1417550716 NPI number — MS. VALOSHA ASHLEIGH ODOM MBA

Table of content: MS. VALOSHA ASHLEIGH ODOM MBA (NPI 1417550716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417550716 NPI number — MS. VALOSHA ASHLEIGH ODOM MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODOM
Provider First Name:
VALOSHA
Provider Middle Name:
ASHLEIGH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417550716
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1273
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAMESTOWN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27282-1273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-828-9083
Provider Business Mailing Address Fax Number:
336-203-2213

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 BRANTMERE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESTOWN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27282-8404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-554-3092
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/18/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X , with the licence number:  N95779 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NP5779 . This is a "NURSING POOL LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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