Provider Demographics
NPI:1114647039
Name:BOURGETTE, KAYCE JUSTINE (FNP)
Entity Type:Individual
Prefix:MS
First Name:KAYCE
Middle Name:JUSTINE
Last Name:BOURGETTE
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Gender:F
Credentials:FNP
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8056
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-747-1171
Mailing Address - Fax:618-622-9724
Practice Address - Street 1:1418 CROSS ST
Practice Address - Street 2:DIV IM MEDICAL ONCOLOGY, STE 180
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2988
Practice Address - Country:US
Practice Address - Phone:800-647-2098
Practice Address - Fax:618-622-9724
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2023-06-21
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Provider Licenses
StateLicense IDTaxonomies
IL209026485363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420115728Medicaid