Healthcare Provider Details

I. General information

NPI: 1982676615
Provider Name (Legal Business Name): BRIDEY LEIGH BOESE RN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRIDEY LEIGH BORRELL

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 4TH ST N
WINSTED MN
55395-4523
US

IV. Provider business mailing address

520 SOUTH SIBLEY AVENUE AFFILIATED COMMUNITY MEDICAL CENTERS
LITCHFIELD MN
55355
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-3190
  • Fax:
Mailing address:
  • Phone: 320-693-3233
  • Fax: 320-693-3290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2005005721
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: