Provider Demographics
NPI:1043469588
Name:BORLA, BERNADETTE JEAN (NP)
Entity Type:Individual
Prefix:MS
First Name:BERNADETTE
Middle Name:JEAN
Last Name:BORLA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27355 JOHN R ROAD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-3327
Mailing Address - Country:US
Mailing Address - Phone:859-420-0822
Mailing Address - Fax:
Practice Address - Street 1:27355 JOHN R RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3327
Practice Address - Country:US
Practice Address - Phone:859-420-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704252212163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704252212OtherST LICS