Active NPI
Janelle L Kyllo Bouchie, PA-C
- Physician Assistant
- Detroit Lakes, MN
National Provider Identifier
1366716102
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 12809
- Practice address
- 1027 Washington Ave
Detroit Lakes, MN 56501-3409 - Phone
- (218) 847-5611
- NPI assigned
- Feb 24, 2012
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Occupational Therapist | 225XP0200X | OT-1120 | ID | |
| Physician Assistant | 363A00000X | 12809 | MN | Primary |
Addresses
Primary practice location
1027 Washington Ave
Detroit Lakes, MN 56501-3409
Mailing address
1702 University Dr S
Fargo, ND 58103-4940
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
Enrollment records 1
Care Compare profile
Medicare Care Compare- Specialty
- Physician Assistant
- Education
- Other, 2018
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
Practice addresses (Care Compare)
1027 Washington Ave
Detroit Lakes, MN 56501-3409
Phone (218) 844-2300
Hospital & facility affiliations
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12809 | MN | MD | Physical Therapist |
| OT-1120 | ID | MD | Pediatric Occupational Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| St. Mary'S Regional Health Center | Current | Accepting new patients | |
| St Mary'S Regional Health Center | Current | Accepting new patients |
Locations
1027 Washington Ave
Detroit Lakes, MN 56501
Phone (218) 844-2300
1702 University Dr S
Fargo, ND 58103
Phone (701) 364-4222
Organizations & group practices 3
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Rural Acute Care Hospital
- Detroit Lakes, MN
- NPI 1679561088
-
- Rural Health Clinic/Center
- Frazee, MN
- NPI 1902364482
-
- Family Medicine Physician
- Lake Park, MN
- NPI 1548604309
Hospital & facility affiliations 4
Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.
-
- Critical Access Hospital
- Park Rapids, MN
- NPI 1023086055
-
- Rural Acute Care Hospital
- Detroit Lakes, MN
- NPI 1679561088
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1330041600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1636502400000",
"number": "1366716102",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1702 UNIVERSITY DR S",
"city": "FARGO",
"state": "ND",
"postal_code": "581034940"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1027 WASHINGTON AVE",
"city": "DETROIT LAKES",
"state": "MN",
"postal_code": "565013409",
"telephone_number": "218-847-5611"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KYLLO BOUCHIE",
"first_name": "JANELLE",
"middle_name": "L",
"credential": "PA-C",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2012-02-24",
"last_updated": "2021-11-10",
"certification_date": "2021-11-10",
"status": "A"
},
"taxonomies": [
{
"code": "225XP0200X",
"taxonomy_group": "",
"desc": "Occupational Therapist, Pediatrics",
"state": "ID",
"license": "OT-1120",
"primary": false
},
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "MN",
"license": "12809",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Detroit Lakes, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 10, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.