Provider Demographics
NPI:1992988539
Name:ODOM, LISA GAILE (APRN-BC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:GAILE
Last Name:ODOM
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 BURNING TREE DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45440-1112
Mailing Address - Country:US
Mailing Address - Phone:713-240-1775
Mailing Address - Fax:
Practice Address - Street 1:1353 N TRAVIS ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-3549
Practice Address - Country:US
Practice Address - Phone:936-336-7316
Practice Address - Fax:936-336-2280
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX658834163WC0200X, 163WE0003X, 163WF0300X, 363LF0000X, 364SE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WF0300XNursing Service ProvidersRegistered NurseFlight
No364SE0003XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistEmergency