Healthcare Provider Details

I. General information

NPI: 1629903901
Provider Name (Legal Business Name): MRS. KATELYNNE EILEEN BODKIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 905
GRANVILLE WV
26534-0905
US

IV. Provider business mailing address

PO BOX 905
GRANVILLE WV
26534-0905
US

V. Phone/Fax

Practice location:
  • Phone: 304-670-0692
  • Fax:
Mailing address:
  • Phone: 304-670-0692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LS0200X
TaxonomySchool Nurse Practitioner
License Number109939
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: