Provider Demographics
NPI:1942317490
Name:VAN DEN BOSCH, LEANN (CNM)
Entity Type:Individual
Prefix:
First Name:LEANN
Middle Name:
Last Name:VAN DEN BOSCH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-5568
Mailing Address - Country:US
Mailing Address - Phone:507-450-3422
Mailing Address - Fax:
Practice Address - Street 1:51 E 4TH ST
Practice Address - Street 2:SUITE 405
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3507
Practice Address - Country:US
Practice Address - Phone:507-454-3680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1302053367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN610022800Medicaid