Provider Demographics
NPI:1881281020
Name:BODNER, EMILY (APRN)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BODNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3465 N PINES WAY
Mailing Address - Street 2:SUITE 104, #32
Mailing Address - City:WILSON
Mailing Address - State:WY
Mailing Address - Zip Code:83014
Mailing Address - Country:US
Mailing Address - Phone:617-312-7737
Mailing Address - Fax:
Practice Address - Street 1:699 FARMHOUSE LN
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-9402
Practice Address - Country:US
Practice Address - Phone:406-556-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-171247363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty