Provider Demographics
NPI:1013287150
Name:PARK, BODANIELLE S (LAC, PHDOM)
Entity Type:Individual
Prefix:DR
First Name:BODANIELLE
Middle Name:S
Last Name:PARK
Suffix:
Gender:F
Credentials:LAC, PHDOM
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 490186
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30049-0004
Mailing Address - Country:US
Mailing Address - Phone:678-878-3069
Mailing Address - Fax:678-878-4455
Practice Address - Street 1:333 SWANSON DR STE 102
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-8537
Practice Address - Country:US
Practice Address - Phone:678-878-3069
Practice Address - Fax:678-878-4455
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-06
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA355171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist