Provider Demographics
NPI:1659806941
Name:ODOM, KIMBERLEY HELEN (FNP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLEY
Middle Name:HELEN
Last Name:ODOM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1550 N CRESTMONT DR STE G
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2177
Mailing Address - Country:US
Mailing Address - Phone:208-629-2023
Mailing Address - Fax:208-759-5840
Practice Address - Street 1:1550 N CRESTMONT DRIVE
Practice Address - Street 2:SUITE G
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-629-2023
Practice Address - Fax:208-759-5840
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ID68579363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily