Provider Demographics
NPI:1952701450
Name:BODENHAMER, TIFFANY A (APRN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:BODENHAMER
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 1:4505 NW FIELDING RD
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66618-2651
Mailing Address - Country:US
Mailing Address - Phone:785-270-0080
Mailing Address - Fax:
Practice Address - Street 1:4505 NW FIELDING RD
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66618-2651
Practice Address - Country:US
Practice Address - Phone:785-270-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS76349363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201102940AMedicaid
KS068002280Medicare PIN