Provider Demographics
NPI:1548910664
Name:BODETTE, MARY ABIGAIL
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ABIGAIL
Last Name:BODETTE
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 1:36605 45TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-8882
Mailing Address - Country:US
Mailing Address - Phone:405-273-1170
Mailing Address - Fax:
Practice Address - Street 1:6100 S WALKER AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-7026
Practice Address - Country:US
Practice Address - Phone:405-634-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist