Provider Demographics
NPI:1760211981
Name:BODDIE, ALEXIS LATREESE (NP)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:LATREESE
Last Name:BODDIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15138 DALMAK GREEN DR
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-5178
Mailing Address - Country:US
Mailing Address - Phone:847-596-0189
Mailing Address - Fax:
Practice Address - Street 1:15138 DALMAK GREEN DR
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-5178
Practice Address - Country:US
Practice Address - Phone:847-596-0189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-27
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1036954363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty