Provider Demographics
NPI:1164155578
Name:BOURGEACQ, ANISSA LYNN (RDN)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:LYNN
Last Name:BOURGEACQ
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8221 SANDPOINT BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7252
Mailing Address - Country:US
Mailing Address - Phone:319-855-0415
Mailing Address - Fax:
Practice Address - Street 1:8221 SANDPOINT BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7252
Practice Address - Country:US
Practice Address - Phone:319-855-0415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-04
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND10630133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered