Healthcare Provider Details

I. General information

NPI: 1588703391
Provider Name (Legal Business Name): LISA LYNN BOVY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 NORTHLAND DR
PRINCETON MN
55371-2172
US

IV. Provider business mailing address

4851 154TH LN NW
RAMSEY MN
55303-6417
US

V. Phone/Fax

Practice location:
  • Phone: 763-389-1313
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9470
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: