Provider Demographics
NPI:1518630623
Name:BOURGEOIS, SUSAN WALSH
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:WALSH
Last Name:BOURGEOIS
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 1:2514 K ST NW APT 17
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-2011
Mailing Address - Country:US
Mailing Address - Phone:407-575-1965
Mailing Address - Fax:
Practice Address - Street 1:2514 K ST NW APT 17
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-2011
Practice Address - Country:US
Practice Address - Phone:407-575-1965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1052089163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse