Provider Demographics
NPI:1154804615
Name:BODENHEIMER, MARY HYACINTH (NURSE PRACTITIONER-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:HYACINTH
Last Name:BODENHEIMER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 S FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-6703
Mailing Address - Country:US
Mailing Address - Phone:352-793-2441
Mailing Address - Fax:352-793-3282
Practice Address - Street 1:212 S FLORIDA ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-6703
Practice Address - Country:US
Practice Address - Phone:352-793-2441
Practice Address - Fax:352-793-3282
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN1782662363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health