Healthcare Provider Details

I. General information

NPI: 1548597008
Provider Name (Legal Business Name): BONNIE RAE ENGEN RN/PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BONNIE RAE DAHLKE RN

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 MAIN AVE N
BAGLEY MN
56621-8313
US

IV. Provider business mailing address

212 MAIN AVE N
BAGLEY MN
56621-8313
US

V. Phone/Fax

Practice location:
  • Phone: 218-694-6581
  • Fax:
Mailing address:
  • Phone: 218-694-6581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR84658-1
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberR84658-1
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR84658-1
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number5540
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: