Healthcare Provider Details

I. General information

NPI: 1003612839
Provider Name (Legal Business Name): KATHRYN ANN BODELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2025
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4075 NIELSON RD
PHELAN CA
92371-8896
US

IV. Provider business mailing address

PO BOX 190
WRIGHTWOOD CA
92397-0190
US

V. Phone/Fax

Practice location:
  • Phone: 760-868-5817
  • Fax:
Mailing address:
  • Phone: 760-646-0832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number128D7E60A2
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: