Provider Demographics
NPI:1568096972
Name:BOURNIAS, JANNINE DENISE (AGNP)
Entity Type:Individual
Prefix:
First Name:JANNINE
Middle Name:DENISE
Last Name:BOURNIAS
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 E STATION RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08226-4451
Mailing Address - Country:US
Mailing Address - Phone:856-625-3547
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL CENTER WAY
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2300
Practice Address - Country:US
Practice Address - Phone:609-653-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00991600363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NJ00991600Medicaid