Healthcare Provider Details

I. General information

NPI: 1578688560
Provider Name (Legal Business Name): LYDIA CORNELL BOURKE N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYDIA WOOD CORNELL N.P.

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2494 S ROCHESTER RD
ROCHESTER HILLS MI
48307-3817
US

IV. Provider business mailing address

472 LINCOLN RD
GROSSE POINTE MI
48230-1609
US

V. Phone/Fax

Practice location:
  • Phone: 248-299-9850
  • Fax: 248-299-9860
Mailing address:
  • Phone: 248-299-9850
  • Fax: 248-299-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number4704215985
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704215985
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: