MEDICARE: MRS. LORI K BOURNE P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA2514	FL

General Provider Information

NPI Number	:	1841449766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LORI K BOURNE P.A.

Provider Business Mailing Address
First Line	:	9960 NW 116TH WAY STE 13
Second Line	:
City	:	MEDLEY
State	:	FL
Zip	:	33178-1175
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1395 N COURTENAY PKWY STE 106
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-4474
Country	:	US
Telephone Number	:	321-452-1224
Fax Number	:	321-453-7784

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2008
Last Update Date	:	01/10/2025

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