Provider Demographics
NPI:1972060184
Name:BODDIE, LARHONDA DENEENE (LPN)
Entity Type:Individual
Prefix:
First Name:LARHONDA
Middle Name:DENEENE
Last Name:BODDIE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:LARHONDA
Other - Middle Name:
Other - Last Name:BODDIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1941 S FORT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48217-1013
Mailing Address - Country:US
Mailing Address - Phone:313-828-3151
Mailing Address - Fax:
Practice Address - Street 1:1941 S FORT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48217-1013
Practice Address - Country:US
Practice Address - Phone:313-828-3151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-24
Last Update Date:2019-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703103136164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse