Provider Demographics
NPI:1982954426
Name:BODU, LYSTRA
Entity Type:Individual
Prefix:
First Name:LYSTRA
Middle Name:
Last Name:BODU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104-14 195 STREET
Mailing Address - Street 2:
Mailing Address - City:ST A;BANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412
Mailing Address - Country:US
Mailing Address - Phone:347-446-8656
Mailing Address - Fax:
Practice Address - Street 1:8825 163 STREET
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:718-739-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303881164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse