Healthcare Provider Details

I. General information

NPI: 1083250864
Provider Name (Legal Business Name): TABITHA NYABOKE BOSIRE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TABITHA NYABOKE OPANDE RN

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 HOSPITAL DR
WINDOM MN
56101-1287
US

IV. Provider business mailing address

2150 HOSPITAL DR
WINDOM MN
56101-1287
US

V. Phone/Fax

Practice location:
  • Phone: 507-831-2400
  • Fax: 507-847-1119
Mailing address:
  • Phone: 507-831-2400
  • Fax: 507-847-1119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5379573-072
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020019972
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11296
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: