Provider Demographics
NPI:1578688560
Name:BOURKE, LYDIA CORNELL (NP)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:CORNELL
Last Name:BOURKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:LYDIA
Other - Middle Name:WOOD
Other - Last Name:CORNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:472 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1609
Mailing Address - Country:US
Mailing Address - Phone:248-299-9850
Mailing Address - Fax:248-299-9860
Practice Address - Street 1:2494 S ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-3817
Practice Address - Country:US
Practice Address - Phone:248-299-9850
Practice Address - Fax:248-299-9860
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704215985163WM0705X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008670700OtherBCBS INDIVIDUAL #
MI4704215985OtherNURSE LICENSE
MI5187136 10Medicaid
MI4704215985OtherNURSE PRACTITIONER LICEN
MIP12300001Medicare PIN