Healthcare Provider Details

I. General information

NPI: 1821200536
Provider Name (Legal Business Name): JULIE KATHERINE BOURQUE RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 S LA PEER DR
BEVERLY HILLS CA
90211-2616
US

IV. Provider business mailing address

106 DESIRE ST
LAFAYETTE LA
70506-6129
US

V. Phone/Fax

Practice location:
  • Phone: 619-861-4777
  • Fax:
Mailing address:
  • Phone: 619-861-4777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number6550044
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number582609-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: