Provider Demographics
NPI:1417550716
Name:ODOM, VALOSHA ASHLEIGH (MBA)
Entity type:Individual
Prefix:MS
First Name:VALOSHA
Middle Name:ASHLEIGH
Last Name:ODOM
Suffix:
Gender:F
Credentials:MBA
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 1273
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-1273
Mailing Address - Country:US
Mailing Address - Phone:773-828-9083
Mailing Address - Fax:336-203-2213
Practice Address - Street 1:105 BRANTMERE CT
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NC
Practice Address - Zip Code:27282-8404
Practice Address - Country:US
Practice Address - Phone:336-554-3092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCN95779251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNP5779OtherNURSING POOL LICENSE