Provider Demographics
NPI:1144560749
Name:BODINE, ELIZABETH A (FNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:BODINE
Suffix:
Gender:F
Credentials:FNP
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 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:25 CONLEY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6477
Practice Address - Country:US
Practice Address - Phone:573-884-0169
Practice Address - Fax:573-884-1137
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013003474363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1144560749Medicaid
MO431560263OtherTRICARE
AR197122758Medicaid
MOP01160136OtherRR MCR
AR197122758Medicaid