Provider Demographics
NPI:1295243848
Name:BODAKUNTA, PRAVEEN (PMHNP)
Entity type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:
Last Name:BODAKUNTA
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 59TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-2858
Mailing Address - Country:US
Mailing Address - Phone:253-620-5015
Mailing Address - Fax:
Practice Address - Street 1:33480 13TH PL S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6357
Practice Address - Country:US
Practice Address - Phone:253-285-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60641646163WP0808X
WAAP60909328363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health