Healthcare Provider Details

I. General information

NPI: 1104590660
Provider Name (Legal Business Name): KIMBERLY C BOURASSA DNP, APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 MARSCHALL RD STE 250
SHAKOPEE MN
55379-2666
US

IV. Provider business mailing address

327 MARSCHALL RD STE 250
SHAKOPEE MN
55379-2666
US

V. Phone/Fax

Practice location:
  • Phone: 651-769-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9071
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: