Basic Information
| Provider Information | |||||||||
| NPI: | 1295243848 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODAKUNTA | ||||||||
| FirstName: | PRAVEEN | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9330 59TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984992858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536205015 | ||||||||
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| Practice Location | |||||||||
| Address1: | 33480 13TH PL S | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532857101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2018 | ||||||||
| LastUpdateDate: | 03/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | A60909328 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 163WP0808X | RN60641646 | WA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.