Provider Demographics
NPI:1831286731
Name:BOULEY, EDMUND A (CNS)
Entity Type:Individual
Prefix:MR
First Name:EDMUND
Middle Name:A
Last Name:BOULEY
Suffix:
Gender:M
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-3619
Mailing Address - Country:US
Mailing Address - Phone:320-219-7518
Mailing Address - Fax:
Practice Address - Street 1:1420 N STATE ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-3619
Practice Address - Country:US
Practice Address - Phone:320-219-7518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX723743163WP0808X, 364SP0808X
MNR178506-5364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX723743OtherNURSING LICENSE
MNR178506-5OtherCLINICAL NURSE SPECIALIST
TX8J9602Medicare PIN