Provider Demographics
NPI:1114700424
Name:BOURQUE, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:RAVENSWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26164-1406
Mailing Address - Country:US
Mailing Address - Phone:304-531-9542
Mailing Address - Fax:
Practice Address - Street 1:714 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:RAVENSWOOD
Practice Address - State:WV
Practice Address - Zip Code:26164-1406
Practice Address - Country:US
Practice Address - Phone:304-531-9542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant