Healthcare Provider Details

I. General information

NPI: 1376810598
Provider Name (Legal Business Name): ERICA RENEE BOURBON ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17065 S. 71 HWY
BELTON MO
64012
US

IV. Provider business mailing address

36123 SCHOOLCRAFT RD
LIVONIA MI
48150-1216
US

V. Phone/Fax

Practice location:
  • Phone: 816-348-1200
  • Fax:
Mailing address:
  • Phone: 913-660-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number77213
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2008030659
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: