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Individual

MCKENNIZIE BOODRAM

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
LAT

Contact information

Practice address
1525 MOUNTAIN LAUREL LN, DESOTO, TX 75115-5394
(469) 260-8872
Mailing address
1525 MOUNTAIN LAUREL LN, DESOTO, TX 75115-5394

Taxonomy

Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
AT6271
TX

Other

Enumeration date
08/26/2015
Last updated
08/26/2015
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