Provider Demographics
NPI:1639930936
Name:BOURRAGE, KIARA (RN)
Entity Type:Individual
Prefix:
First Name:KIARA
Middle Name:
Last Name:BOURRAGE
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 1:12485 SCHAMBERVILLE LN
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39325-9195
Mailing Address - Country:US
Mailing Address - Phone:601-663-6145
Mailing Address - Fax:
Practice Address - Street 1:16412 HIGHWAY 16 E
Practice Address - Street 2:
Practice Address - City:DE KALB
Practice Address - State:MS
Practice Address - Zip Code:39328-5507
Practice Address - Country:US
Practice Address - Phone:601-480-4754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS908254163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse