1518509025 NPI number — MRS. CANDICE BODDY CNM

Table of content: MRS. CANDICE BODDY CNM (NPI 1518509025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518509025 NPI number — MRS. CANDICE BODDY CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BODDY
Provider First Name:
CANDICE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518509025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9500 EUCLID AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44195-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
162-376-3002
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 BELLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44107-4211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-237-6300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  APRN.CNM.019405 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 104542200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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