Provider Demographics
NPI:1104417021
Name:ODOM, DIANNA (PA-C)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MOHAWK CIR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-2515
Mailing Address - Country:US
Mailing Address - Phone:479-970-4064
Mailing Address - Fax:
Practice Address - Street 1:2933 LAKEWOOD VILLAGE DR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-8033
Practice Address - Country:US
Practice Address - Phone:501-435-1417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant