Provider Demographics
NPI:1841420627
Name:BOURDEAU, ERICA LYNNE (NP)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LYNNE
Last Name:BOURDEAU
Suffix:
Gender:F
Credentials:NP
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 1138
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-1138
Mailing Address - Country:US
Mailing Address - Phone:540-688-2646
Mailing Address - Fax:540-688-2656
Practice Address - Street 1:25 MYERS CORNER DR
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-6342
Practice Address - Country:US
Practice Address - Phone:540-688-2646
Practice Address - Fax:540-688-2656
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY420938207V00000X, 363LW0102X
VA0024175290363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03133759Medicaid
NY03133759Medicaid