MEDICARE: KATHLEEN JUNE BOUSU RN IBCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WL0100X	Lactation Consultant (Registered Nurse)	1180068	MN

General Provider Information

NPI Number	:	1467117200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN JUNE BOUSU RN IBCLC

Provider Business Mailing Address
First Line	:	7909 QUINCY ST NE
Second Line	:
City	:	SPRING LAKE PARK
State	:	MN
Zip	:	55432-1974
Country	:	US
Telephone Number	:	763-342-1752
Fax Number	:

Provider Business Practice Location Address
First Line	:	7909 QUINCY ST NE
Second Line	:
City	:	SPRING LAKE PARK
State	:	MN
Zip	:	55432-1974
Country	:	US
Telephone Number	:	763-342-1752
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2021
Last Update Date	:	11/06/2021

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