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General NPI Number Information
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NPI Number | 1497237796
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Entity Type | Individual
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Provider Name | MR. KIRKWOOD BODDEN SR.
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Gender | Male
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Dates
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Enumeration Date | 09/04/2018
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Last Update Date | 10/23/2019
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Provider Practice Location Address
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Address Line | 150 BERGEN ST
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City | NEWARK
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State | NJ
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Zip | 07103-2496
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Country | US
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Telephone | 973-972-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 2106 ACKMEN CT
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City | BRIDGEWATER
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State | NJ
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Zip | 08807-3558
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Country | US
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Telephone | 908-393-4630
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 26NJ00644200
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 26NR16031700
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License Number State | NJ
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