Healthcare Provider Details

I. General information

NPI: 1407828023
Provider Name (Legal Business Name): JUDITH BOURLAND RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 EXCHANGE ST W #222
SAINT PAUL MN
55102-1045
US

IV. Provider business mailing address

17 EXCHANGE ST W #222
SAINT PAUL MN
55102-1045
US

V. Phone/Fax

Practice location:
  • Phone: 651-602-0101
  • Fax: 651-602-0035
Mailing address:
  • Phone: 651-602-0101
  • Fax: 651-602-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberR1025893
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: