Provider Demographics
NPI:1760259212
Name:BOURNE, ARMANDA L (PT)
Entity Type:Individual
Prefix:
First Name:ARMANDA
Middle Name:L
Last Name:BOURNE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654-0457
Mailing Address - Country:US
Mailing Address - Phone:601-587-2563
Mailing Address - Fax:
Practice Address - Street 1:314 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-3702
Practice Address - Country:US
Practice Address - Phone:601-587-2563
Practice Address - Fax:601-587-0472
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT7650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist