Provider Demographics
NPI:1407503717
Name:BODAK NICHOLSON, STEPHANIE ANN (IBCLC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:BODAK NICHOLSON
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15047 DOVE RD
Mailing Address - Street 2:
Mailing Address - City:MOODY
Mailing Address - State:TX
Mailing Address - Zip Code:76557-3160
Mailing Address - Country:US
Mailing Address - Phone:254-913-6939
Mailing Address - Fax:
Practice Address - Street 1:15047 DOVE RD
Practice Address - Street 2:
Practice Address - City:MOODY
Practice Address - State:TX
Practice Address - Zip Code:76557-3160
Practice Address - Country:US
Practice Address - Phone:254-913-6939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL-301558174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN