Provider Demographics
NPI:1629358866
Name:BODKER, THERESA FREDERICK (APRN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:FREDERICK
Last Name:BODKER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 62600
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70162-2600
Mailing Address - Country:US
Mailing Address - Phone:337-706-1506
Mailing Address - Fax:337-981-9257
Practice Address - Street 1:1211 COOLIDGE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2636
Practice Address - Country:US
Practice Address - Phone:337-289-8400
Practice Address - Fax:337-289-8401
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAAP01091364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist