Basic Information
| Provider Information | |||||||||
| NPI: | 1982676615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOESE | ||||||||
| FirstName: | BRIDEY | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | RN CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BORRELL | ||||||||
| OtherFirstName: | BRIDEY | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 520 SOUTH SIBLEY AVENUE | ||||||||
| Address2: | AFFILIATED COMMUNITY MEDICAL CENTERS | ||||||||
| City: | LITCHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206933233 | ||||||||
| FaxNumber: | 3206933290 | ||||||||
| Practice Location | |||||||||
| Address1: | 551 4TH ST N | ||||||||
| Address2: | |||||||||
| City: | WINSTED | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553954523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524423190 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 10/28/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2005005721 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.