Provider Demographics
NPI:1003612839
Name:BODELL, KATHRYN ANN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:BODELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:WRIGHTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:92397-0190
Mailing Address - Country:US
Mailing Address - Phone:760-646-0832
Mailing Address - Fax:
Practice Address - Street 1:4075 NIELSON RD
Practice Address - Street 2:
Practice Address - City:PHELAN
Practice Address - State:CA
Practice Address - Zip Code:92371-8896
Practice Address - Country:US
Practice Address - Phone:760-868-5817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128D7E60A2172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker