Provider Demographics
NPI:1285426718
Name:BODHI WELLNESS LLC
Entity type:Organization
Organization Name:BODHI WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:COULSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:757-239-5858
Mailing Address - Street 1:1832 KENPSVILLE RD STE 112
Mailing Address - Street 2:
Mailing Address - City:LA BREAK
Mailing Address - State:VA
Mailing Address - Zip Code:23116
Mailing Address - Country:US
Mailing Address - Phone:757-239-5858
Mailing Address - Fax:
Practice Address - Street 1:1832 KENPSVILLE RD STE 112
Practice Address - Street 2:
Practice Address - City:LA BREAK
Practice Address - State:VA
Practice Address - Zip Code:23116
Practice Address - Country:US
Practice Address - Phone:757-239-5858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty