Provider Demographics
NPI:1689223208
Name:BODFISH, EMILY JANE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:JANE
Last Name:BODFISH
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 1:171 HUTTON ST APT 7
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-3492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1204 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4312
Practice Address - Country:US
Practice Address - Phone:276-783-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-006874363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical