Healthcare Provider Details

I. General information

NPI: 1013323203
Provider Name (Legal Business Name): MARLEE BODLE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARLEE MCKENZIE CRNA

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 03/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CHURCH ST N
CONCORD NC
28025-2927
US

IV. Provider business mailing address

896 STILLWATER DR
CHARLESTON SC
29412-4922
US

V. Phone/Fax

Practice location:
  • Phone: 704-403-1412
  • Fax:
Mailing address:
  • Phone: 843-425-4737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number205465
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number276152
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: