Healthcare Provider Details

I. General information

NPI: 1053732271
Provider Name (Legal Business Name): DANETTE BOURQUIN L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2013
Last Update Date: 12/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 N LAFAYETTE AVE
FULDA MN
56131-9201
US

IV. Provider business mailing address

607 N LAFAYETTE AVE
FULDA MN
56131-9201
US

V. Phone/Fax

Practice location:
  • Phone: 507-227-5873
  • Fax:
Mailing address:
  • Phone: 507-227-5873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1691
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: