Individual
JANELLE L KYLLO BOUCHIE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1027 WASHINGTON AVE, DETROIT LAKES, MN 56501-3409
(218) 847-5611
Mailing address
1702 UNIVERSITY DR S, FARGO, ND 58103-4940
Taxonomy
Speciality
Code
Description
License number
State
225XP0200X
Pediatric Occupational Therapist
OT-1120
ID
363A00000X
Physician Assistant
Primary
12809
MN
Other
Enumeration date
02/24/2012
Last updated
11/10/2021
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