Healthcare Provider Details

I. General information

NPI: 1548798564
Provider Name (Legal Business Name): NICHOLAS JOSEPH BODI FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2017
Last Update Date: 06/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 S BRENTWOOD BLVD STE 415
SAINT LOUIS MO
63117-1204
US

IV. Provider business mailing address

151 CRESCENT AVE
VALLEY PARK MO
63088-1106
US

V. Phone/Fax

Practice location:
  • Phone: 314-293-8123
  • Fax:
Mailing address:
  • Phone: 636-575-2115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017010493
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: