Healthcare Provider Details

I. General information

NPI: 1861236507
Provider Name (Legal Business Name): CELENA BODIE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 SE 3RD AVE STE 721
FORT LAUDERDALE FL
33316-2591
US

IV. Provider business mailing address

1700 NW 49TH ST STE 125
FORT LAUDERDALE FL
33309-3750
US

V. Phone/Fax

Practice location:
  • Phone: 954-355-4617
  • Fax: 954-355-4618
Mailing address:
  • Phone: 954-355-4617
  • Fax: 954-355-4618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11031972
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: