Provider Demographics
NPI:1225420136
Name:BOURDLAIS, CHRISTY (NP)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:
Last Name:BOURDLAIS
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 1:1019 CAMPUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307
Mailing Address - Country:US
Mailing Address - Phone:231-591-5961
Mailing Address - Fax:231-591-5970
Practice Address - Street 1:1019 CAMPUS DRIVE
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307
Practice Address - Country:US
Practice Address - Phone:231-591-5961
Practice Address - Fax:231-591-5970
Is Sole Proprietor?:No
Enumeration Date:2015-03-02
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704282976363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
APPLIED FORMedicare UPIN