Provider Demographics
NPI:1851838809
Name:BOURGON, KRISTEN (MSN, AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:BOURGON
Suffix:
Gender:F
Credentials:MSN, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20075 NORTHVILLE PLACE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2984
Mailing Address - Country:US
Mailing Address - Phone:248-672-2271
Mailing Address - Fax:
Practice Address - Street 1:21650 W 11 MILE RD STE 202
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3777
Practice Address - Country:US
Practice Address - Phone:248-327-6196
Practice Address - Fax:248-327-6356
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704277091363LA2200X, 363LG0600X, 363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care