Provider Demographics
NPI:1700493525
Name:BAK, EMILIE M (RN)
Entity Type:Individual
Prefix:
First Name:EMILIE
Middle Name:M
Last Name:BAK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:EMILIE
Other - Middle Name:M
Other - Last Name:BOEVER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:1601 EAGLES CREST AVE UNIT F5
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-5065
Mailing Address - Country:US
Mailing Address - Phone:563-650-6877
Mailing Address - Fax:
Practice Address - Street 1:601 HIGHWAY 6 W
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52246-2209
Practice Address - Country:US
Practice Address - Phone:319-338-0581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041446999163W00000X
IA158617163WM0705X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical