Provider Demographics
NPI:1821781881
Name:BOLDUC, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BOLDUC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:KOHOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:301 BECKER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3302
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:
Practice Address - Street 1:301 BECKER AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MS
Practice Address - Zip Code:56271
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2351566163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse