Healthcare Provider Details

I. General information

NPI: 1841494556
Provider Name (Legal Business Name): LISA BOLLE RN,CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 BECKER AVE SW
WILLMAR MN
56201-3302
US

IV. Provider business mailing address

311 LAKE AVE N
SPICER MN
56288-9513
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-8740
  • Fax: 320-231-8741
Mailing address:
  • Phone: 320-231-0874
  • Fax: 320-231-8741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number128943-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: