Provider Demographics
NPI:1235789264
Name:BODDIE, MICHAEL ANTHONY SR (RN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:BODDIE
Suffix:SR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4539 DAYTON LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-5905
Mailing Address - Country:US
Mailing Address - Phone:937-694-3671
Mailing Address - Fax:
Practice Address - Street 1:4539 DAYTON LIBERTY RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-5905
Practice Address - Country:US
Practice Address - Phone:937-694-3671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH231442163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse