Provider Demographics
NPI:1689104192
Name:BOURDEAU, SOPHIA (LPN)
Entity Type:Individual
Prefix:MS
First Name:SOPHIA
Middle Name:
Last Name:BOURDEAU
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 SW SOUTH DANVILLE CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5929
Mailing Address - Country:US
Mailing Address - Phone:754-234-3487
Mailing Address - Fax:
Practice Address - Street 1:159 SW SOUTH DANVILLE CIR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-5929
Practice Address - Country:US
Practice Address - Phone:754-234-3487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities