Provider Demographics
NPI:1568071116
Name:BODNAR, CARIE ELISE (ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:CARIE
Middle Name:ELISE
Last Name:BODNAR
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17152 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:TX
Mailing Address - Zip Code:75762-9237
Mailing Address - Country:US
Mailing Address - Phone:757-692-7703
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST STE 500
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8365
Practice Address - Country:US
Practice Address - Phone:757-692-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1005219363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care