Healthcare Provider Details

I. General information

NPI: 1629595160
Provider Name (Legal Business Name): DIANNE LYNN BOURNE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 ENCINO PL NE STE 26
ALBUQUERQUE NM
87102-2629
US

IV. Provider business mailing address

717 ENCINO PL NE STE 26
ALBUQUERQUE NM
87102-2629
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-4545
  • Fax: 505-884-4114
Mailing address:
  • Phone: 505-884-4545
  • Fax: 505-884-4114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-03360
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: