Provider Demographics
NPI:1962095612
Name:ODOM, COURTNEY CHAVIS (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:CHAVIS
Last Name:ODOM
Suffix:
Gender:F
Credentials:FNP-C
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 1090
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1090
Mailing Address - Country:US
Mailing Address - Phone:843-857-0111
Mailing Address - Fax:
Practice Address - Street 1:3080 HIGHWAY 15-401 E
Practice Address - Street 2:
Practice Address - City:MC COLL
Practice Address - State:SC
Practice Address - Zip Code:29570-6128
Practice Address - Country:US
Practice Address - Phone:843-523-5751
Practice Address - Fax:843-523-6040
Is Sole Proprietor?:No
Enumeration Date:2021-02-13
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC225769163W00000X
NC5015042363LF0000X
SC25309363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP8401Medicaid
SCSCM901OtherMEDICARE