Provider Demographics
NPI:1386372332
Name:ODOM, OLIVIA GRACE (RD, LD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GRACE
Last Name:ODOM
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14155 DALLAS PARKWAY
Mailing Address - Street 2:APT 1148
Mailing Address - City:FARMERS BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:75254
Mailing Address - Country:US
Mailing Address - Phone:337-852-6823
Mailing Address - Fax:
Practice Address - Street 1:1600 W COLLEGE ST STE 190
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-2100
Practice Address - Country:US
Practice Address - Phone:817-305-5061
Practice Address - Fax:817-305-5013
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT87897133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered