Provider Demographics
NPI:1720462187
Name:BOGE, ANNA (LMT, MMP)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:BOGE
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 130TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52776-9121
Mailing Address - Country:US
Mailing Address - Phone:563-564-0720
Mailing Address - Fax:
Practice Address - Street 1:1395 JORDAN ST
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-4759
Practice Address - Country:US
Practice Address - Phone:319-774-3811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA006773225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist