Healthcare Provider Details

I. General information

NPI: 1699415547
Provider Name (Legal Business Name): ERIN BOURQUE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 EMERY MILLS RD
LEBANON ME
04027-3129
US

IV. Provider business mailing address

55 EMERY MILLS RD
LEBANON ME
04027-3129
US

V. Phone/Fax

Practice location:
  • Phone: 505-803-4469
  • Fax:
Mailing address:
  • Phone: 505-803-4469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN66600
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number087754-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: