Provider Demographics
NPI:1649076555
Name:BEMBOOM, MIRANDA MARIE (RN, BSN)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MARIE
Last Name:BEMBOOM
Suffix:
Gender:
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11112 60TH ST NE
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56329-4552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4801 VETERANS DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2015
Practice Address - Country:US
Practice Address - Phone:320-252-1680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2459726163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse