Provider Demographics
NPI:1376810598
Name:BOURBON, ERICA RENEE (ANP-BC)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:RENEE
Last Name:BOURBON
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36123 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1216
Mailing Address - Country:US
Mailing Address - Phone:913-660-1616
Mailing Address - Fax:
Practice Address - Street 1:17065 S. 71 HWY
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012
Practice Address - Country:US
Practice Address - Phone:816-348-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS77213363L00000X
MO2008030659363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner