Provider Demographics
NPI:1215492426
Name:BOSAAEN, BRENDA ANN
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:ANN
Last Name:BOSAAEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2884 W RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-6211
Mailing Address - Country:US
Mailing Address - Phone:320-679-0511
Mailing Address - Fax:
Practice Address - Street 1:2884 W RIVER RD
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-6211
Practice Address - Country:US
Practice Address - Phone:320-679-0511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health