| Doctor Name: | MCKENNIZIE BOODRAM |
| NPI Number: | 1033586003 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LAT |
| License Number: | AT6271 |
| Business Practice Address: | 1525 Mountain Laurel Ln Desoto, TX - 751155394 |
| Business Phone Number: | 4692608872 |
| Business Fax Number: | |
| Mailing Address: | 1525 Mountain Laurel Ln, DESOTO |
| State: | TX |
| Postal Code: | 751155394 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 08/26/2015 |
| NPI Last Update Date: | 08/26/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 171W00000X |
| License Number: | AT6271 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TX |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Contractor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A person who contracts to supply certain materials or do certain work for a stipulated sum; esp., one whose business is contracting work in any of the building trades. For purposes of the taxonomy, a person who contracts to complete home repairs or modifications to accommodate a health condition (e.g. wheelchair ramp, kitchen counter lowering). |