Provider Demographics
NPI:1811734148
Name:BOTHUN, MARY ANN (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:BOTHUN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2558 180TH ST
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:MN
Mailing Address - Zip Code:56220-3395
Mailing Address - Country:US
Mailing Address - Phone:320-444-8234
Mailing Address - Fax:
Practice Address - Street 1:1282 WALNUT ST
Practice Address - Street 2:
Practice Address - City:DAWSON
Practice Address - State:MN
Practice Address - Zip Code:56232-2333
Practice Address - Country:US
Practice Address - Phone:320-312-2133
Practice Address - Fax:320-769-4576
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2517858163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse