Provider Demographics
NPI:1265854632
Name:BOELTER, ABBY (LPN, IBCLC)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:
Last Name:BOELTER
Suffix:
Gender:F
Credentials:LPN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CENTRACARE CIR STE 1300
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-654-3610
Mailing Address - Fax:320-654-3647
Practice Address - Street 1:1900 CENTRACARE CIR STE 1300
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-654-3610
Practice Address - Fax:320-654-3647
Is Sole Proprietor?:No
Enumeration Date:2014-01-20
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL64140-1164W00000X
MNL-46770174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No164W00000XNursing Service ProvidersLicensed Practical Nurse