Provider Demographics
NPI:1922656198
Name:BODDEN, ANGELLE N
Entity Type:Individual
Prefix:
First Name:ANGELLE
Middle Name:N
Last Name:BODDEN
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 1:1799 STUMPF BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:TERRYTOWN
Mailing Address - State:LA
Mailing Address - Zip Code:70056-3950
Mailing Address - Country:US
Mailing Address - Phone:504-249-2239
Mailing Address - Fax:
Practice Address - Street 1:1799 STUMPF BLVD BLDG 1 STE 1
Practice Address - Street 2:
Practice Address - City:GRENTA
Practice Address - State:LA
Practice Address - Zip Code:70056-3950
Practice Address - Country:US
Practice Address - Phone:504-249-2239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA009776805171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator