Healthcare Provider Details

I. General information

NPI: 1902808843
Provider Name (Legal Business Name): MARCIA BOURQUE-MORENO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WELLS ST
WESTERLY RI
02891-2922
US

IV. Provider business mailing address

74 CLEVELAND ST
NORFOLK MA
02056-1048
US

V. Phone/Fax

Practice location:
  • Phone: 401-596-6000
  • Fax:
Mailing address:
  • Phone: 508-520-2302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number193379
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN01004
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: