Provider Demographics
NPI:1235869942
Name:BOEHM, MIRANDA LYNN
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LYNN
Last Name:BOEHM
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 1:816 8TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-1412
Mailing Address - Country:US
Mailing Address - Phone:218-469-9392
Mailing Address - Fax:
Practice Address - Street 1:3701 12TH ST N STE 202
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2253
Practice Address - Country:US
Practice Address - Phone:309-032-0258
Practice Address - Fax:320-258-3095
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2733367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered