Healthcare Provider Details

I. General information

NPI: 1720562010
Provider Name (Legal Business Name): ALLYSSA BODDY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35700 WARREN RD STE C
WESTLAND MI
48185-3808
US

IV. Provider business mailing address

9029 PARDEE RD
TAYLOR MI
48180-2755
US

V. Phone/Fax

Practice location:
  • Phone: 313-437-8427
  • Fax: 313-437-8429
Mailing address:
  • Phone: 313-437-8427
  • Fax: 313-447-8429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number4704292285
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704292285
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: