Provider Demographics
NPI:1457571028
Name:BODLE-PEDERSEN, BARBARA JEAN (MSN, MPH, FNP)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:JEAN
Last Name:BODLE-PEDERSEN
Suffix:
Gender:F
Credentials:MSN, MPH, FNP
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:JEAN
Other - Last Name:BODLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN,MPH,FNP
Mailing Address - Street 1:77 FRANCISCAN WAY
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:94707-1112
Mailing Address - Country:US
Mailing Address - Phone:510-525-9206
Mailing Address - Fax:
Practice Address - Street 1:2222 BANCROFT AVE.
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-4300
Practice Address - Country:US
Practice Address - Phone:510-643-7117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293413, 3383363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA293413, 3383OtherREGISTERED NURSE, NP