Healthcare Provider Details

I. General information

NPI: 1316311905
Provider Name (Legal Business Name): LUCY BOURESSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 E. ENTERPRISE AVE 113
APPLETON WI
54913
US

IV. Provider business mailing address

2105 E. ENTERPRISE AVE 113
APPLETON WI
54913
US

V. Phone/Fax

Practice location:
  • Phone: 920-991-2561
  • Fax: 920-991-2563
Mailing address:
  • Phone: 920-991-2561
  • Fax: 920-991-2563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: