Provider Demographics
NPI:1639534399
Name:BODINE, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BODINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 JESSE WAY
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-5581
Mailing Address - Country:US
Mailing Address - Phone:909-206-3717
Mailing Address - Fax:
Practice Address - Street 1:111 LAKE HOLLINGSWORTH DR
Practice Address - Street 2:BOX 4102
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801
Practice Address - Country:US
Practice Address - Phone:909-206-3717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program