Healthcare Provider Details

I. General information

NPI: 1568096972
Provider Name (Legal Business Name): JANNINE DENISE BOURNIAS AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL CENTER WAY
SOMERS POINT NJ
08244-2300
US

IV. Provider business mailing address

33 E STATION RD
OCEAN CITY NJ
08226-4451
US

V. Phone/Fax

Practice location:
  • Phone: 609-653-3500
  • Fax:
Mailing address:
  • Phone: 856-625-3547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00991600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: