Healthcare Provider Details

I. General information

NPI: 1114525706
Provider Name (Legal Business Name): JENNIFER BODINE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 BATTLEFIELD BLVD N
CHESAPEAKE VA
23320-4941
US

IV. Provider business mailing address

PO BOX 11314
BELFAST ME
04915-4004
US

V. Phone/Fax

Practice location:
  • Phone: 757-312-8121
  • Fax:
Mailing address:
  • Phone: 757-842-4481
  • Fax: 757-312-3135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024179734
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: