Provider Demographics
NPI:1447924055
Name:BODEKER, EMMA MARIE
Entity type:Individual
Prefix:MS
First Name:EMMA
Middle Name:MARIE
Last Name:BODEKER
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:EMMA
Other - Middle Name:MARIE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:111 MALTESE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2141
Mailing Address - Country:US
Mailing Address - Phone:845-342-4774
Mailing Address - Fax:
Practice Address - Street 1:111 MALTESE DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2141
Practice Address - Country:US
Practice Address - Phone:845-342-4774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348251363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06873798Medicaid