MEDICARE: KELLIE BOEGGEMAN DEARDEN ARNP

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	363L00000X	Nurse Practitioner	248427	NC
2	363LF0000X	Family Nurse Practitioner	9165739	FL
3	363L00000X	Nurse Practitioner	APN355	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669662086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE BOEGGEMAN DEARDEN ARNP

Provider Business Mailing Address
First Line	:	16706 NE 98TH ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98682-1275
Country	:	US
Telephone Number	:
Fax Number	:	803-888-2299

Provider Business Practice Location Address
First Line	:	885 3RD AVE FL 28
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-4834
Country	:	US
Telephone Number	:	929-650-3990
Fax Number	:

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

Provider Enumeration Date	:	08/01/2007
Last Update Date	:	04/23/2025

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