Provider Demographics
NPI:1104332527
Name:ODOM, TRACY (CRNP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ODOM
Suffix:
Gender:
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 342
Mailing Address - Street 2:
Mailing Address - City:FLORALA
Mailing Address - State:AL
Mailing Address - Zip Code:36442-0342
Mailing Address - Country:US
Mailing Address - Phone:334-809-8049
Mailing Address - Fax:
Practice Address - Street 1:101 E PAULK AVE STE A
Practice Address - Street 2:
Practice Address - City:OPP
Practice Address - State:AL
Practice Address - Zip Code:36467-1727
Practice Address - Country:US
Practice Address - Phone:334-493-0311
Practice Address - Fax:334-493-0355
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-111973364SF0001X, 363L00000X, 2084P0800X
FLAPRN11001967363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL305045Medicaid
19C1ROtherNEW DIRECTIONS
AL188102Medicaid
523314OtherVALUE OPTIONS
AL229432Medicaid
1013117167OtherNPI
1104332527OtherNPI
GA407098142CMedicaid
AL529920780Medicaid
601701400OtherDOL
83-0392317OtherTAX ID
Q6YNLOtherFLORIDA BLUE
7740890000OtherMAGELLAN