Provider Demographics
NPI:1083056386
Name:ODOR, LANISSA DANIELLE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:LANISSA
Middle Name:DANIELLE
Last Name:ODOR
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2085 GOODMAN RD W
Mailing Address - Street 2:SUITE 50
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-1416
Mailing Address - Country:US
Mailing Address - Phone:662-253-8459
Mailing Address - Fax:
Practice Address - Street 1:2085 GOODMAN RD W
Practice Address - Street 2:SUITE 50
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1416
Practice Address - Country:US
Practice Address - Phone:662-253-8459
Practice Address - Fax:662-253-8678
Is Sole Proprietor?:No
Enumeration Date:2013-07-27
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17722363LF0000X
MSA810645363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily