Provider Demographics
NPI:1568816171
Name:BODLE, STACY MARIE (LPN)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MARIE
Last Name:BODLE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14302 BRITTANY TER
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-7156
Mailing Address - Country:US
Mailing Address - Phone:503-546-9421
Mailing Address - Fax:
Practice Address - Street 1:420 NE MASON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3479
Practice Address - Country:US
Practice Address - Phone:506-546-9421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200730013LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse