Healthcare Provider Details

I. General information

NPI: 1114611894
Provider Name (Legal Business Name): ASHLEY BOOM BUCKNER CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY ANN BOOM CF-SLP

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 4TH AVE NW
MINOT ND
58703
US

IV. Provider business mailing address

34 OLIVE TREE CIR NE
MINOT ND
58703
US

V. Phone/Fax

Practice location:
  • Phone: 701-839-1311
  • Fax:
Mailing address:
  • Phone: 701-709-0049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2408
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: