Provider Demographics
NPI:1124734553
Name:BODINE, KATHRIN (NP)
Entity type:Individual
Prefix:
First Name:KATHRIN
Middle Name:
Last Name:BODINE
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 1:1213 S ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2013
Mailing Address - Country:US
Mailing Address - Phone:503-480-6224
Mailing Address - Fax:
Practice Address - Street 1:100 W MAIN ST STE 204
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7362
Practice Address - Country:US
Practice Address - Phone:208-495-4145
Practice Address - Fax:833-740-4395
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID65244363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID65244OtherIDAHO APRN LICENSE / IDAHO STATE BOARD OF NURSING