Healthcare Provider Details

I. General information

NPI: 1831286731
Provider Name (Legal Business Name): EDMUND A BOULEY CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 06/28/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 N STATE ST
FAIRMONT MN
56031-3619
US

IV. Provider business mailing address

1420 N STATE ST
FAIRMONT MN
56031-3619
US

V. Phone/Fax

Practice location:
  • Phone: 320-219-7518
  • Fax:
Mailing address:
  • Phone: 320-219-7518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number723743
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number723743
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberR178506-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: