Provider Demographics
NPI:1285114553
Name:BODINE, ANN MARIE
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:BODINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:MARIE
Other - Last Name:STAVINOHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5455 KNICKERBOCKER RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-7711
Mailing Address - Country:US
Mailing Address - Phone:325-944-1600
Mailing Address - Fax:
Practice Address - Street 1:5455 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7711
Practice Address - Country:US
Practice Address - Phone:325-944-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2087170225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant