Healthcare Provider Details

I. General information

NPI: 1598963886
Provider Name (Legal Business Name): BETSY JOELLE BODIE ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ELM AND CARLTON STREETS
BUFFALO NY
14263
US

IV. Provider business mailing address

ELM AND CARLTON STREETS
BUFFALO NY
14263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-2300
  • Fax: 716-845-8057
Mailing address:
  • Phone: 716-845-2300
  • Fax: 716-845-8057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF304599-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF304599-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: