Provider Demographics
NPI:1972098465
Name:ODOM, NKENNA (MD)
Entity type:Individual
Prefix:
First Name:NKENNA
Middle Name:
Last Name:ODOM
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Gender:
Credentials:MD
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Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:PRC AND CREDENTIALING
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-273-0641
Mailing Address - Fax:401-273-2919
Practice Address - Street 1:1195 NORTH MAIN STREET
Practice Address - Street 2:CNEMG PRIMARY CARE WMC
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-0288
Practice Address - Country:US
Practice Address - Phone:401-736-4562
Practice Address - Fax:401-921-9864
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2025-02-19
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Provider Licenses
StateLicense IDTaxonomies
RIMD17589207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine