Provider Demographics
NPI:1598588782
Name:ODOM, VANESSA STEPHANY (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:STEPHANY
Last Name:ODOM
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HIGHPOINT
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1946
Mailing Address - Country:US
Mailing Address - Phone:949-702-4692
Mailing Address - Fax:
Practice Address - Street 1:30 HIGHPOINT
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-1946
Practice Address - Country:US
Practice Address - Phone:949-702-4692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-312523163WL0100X
CA95051424163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant