Provider Demographics
NPI:1063491892
Name:BOURLIER-CHILDRESS, JOANN (PAC)
Entity Type:Individual
Prefix:MS
First Name:JOANN
Middle Name:
Last Name:BOURLIER-CHILDRESS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3748
Mailing Address - Country:US
Mailing Address - Phone:307-634-2273
Mailing Address - Fax:
Practice Address - Street 1:214 E 23RD ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3748
Practice Address - Country:US
Practice Address - Phone:307-634-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE692363A00000X
WY463363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49876317Medicaid
NENE692Medicaid
CO49876317Medicaid
NENE692Medicaid
S59477Medicare UPIN