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General NPI Number Information
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NPI Number | 1376810598
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Entity Type | Individual
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Provider Name | ERICA RENEE BOURBON ANP-BC
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Gender | Female
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Dates
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Enumeration Date | 11/17/2011
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Last Update Date | 04/06/2018
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Provider Practice Location Address
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Address Line | 17065 S. 71 HWY
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City | BELTON
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State | MO
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Zip | 64012
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Country | US
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Telephone | 816-348-1200
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Fax |
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Provider Business Mailing Address
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Address Line | 36123 SCHOOLCRAFT RD
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City | LIVONIA
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State | MI
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Zip | 48150-1216
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Country | US
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Telephone | 913-660-1616
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 77213
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 2008030659
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License Number State | MO
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