MEDICARE: ADELLA J BODDEN LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	220299	NY

General Provider Information

NPI Number	:	1881926467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADELLA J BODDEN LPN

Provider Business Mailing Address
First Line	:	961 E 94TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-2023
Country	:	US
Telephone Number	:	917-459-8578
Fax Number	:

Provider Business Practice Location Address
First Line	:	961 E 94TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-2023
Country	:	US
Telephone Number	:	917-459-8578
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2010
Last Update Date	:	02/05/2010

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