Provider Demographics
NPI:1316566433
Name:BOSSUYT, KYLIE LINDEN
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:LINDEN
Last Name:BOSSUYT
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 1:1521 CARLSON ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-2626
Mailing Address - Country:US
Mailing Address - Phone:507-476-4800
Mailing Address - Fax:
Practice Address - Street 1:1521 CARLSON ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2626
Practice Address - Country:US
Practice Address - Phone:507-476-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN74611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program