Provider Demographics
NPI:1407269400
Name:BOURGEOIS, REBECCA (RN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 GENESEE ST
Mailing Address - Street 2:BUSINESS OFFICE
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5930
Mailing Address - Country:US
Mailing Address - Phone:315-801-4238
Mailing Address - Fax:315-801-8391
Practice Address - Street 1:1903 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5617
Practice Address - Country:US
Practice Address - Phone:315-624-8150
Practice Address - Fax:315-797-1537
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily