Provider Demographics
NPI:1578094116
Name:BOOKOUT, JODIE LYNN (RN)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:LYNN
Last Name:BOOKOUT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S NICKEL ST
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-6301
Mailing Address - Country:US
Mailing Address - Phone:575-546-2678
Mailing Address - Fax:575-544-0918
Practice Address - Street 1:1100 S NICKEL ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-6301
Practice Address - Country:US
Practice Address - Phone:575-546-2678
Practice Address - Fax:575-544-0918
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR57019163W00000X
NM345592163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163W00000XNursing Service ProvidersRegistered Nurse