MEDICARE: LOIS E BOERBOOM RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R91174-6	MN

General Provider Information

NPI Number	:	1184929952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOIS E BOERBOOM RN

Provider Business Mailing Address
First Line	:	15402 140TH ST
Second Line	:
City	:	WALNUT GROVE
State	:	MN
Zip	:	56180-5311
Country	:	US
Telephone Number	:	507-859-2582
Fax Number	:

Provider Business Practice Location Address
First Line	:	15402 140TH ST
Second Line	:
City	:	WALNUT GROVE
State	:	MN
Zip	:	56180-5311
Country	:	US
Telephone Number	:	507-859-2582
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2011
Last Update Date	:	02/02/2011

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Directions to “ LOIS E BOERBOOM RN” Practice Location

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