Provider Demographics
NPI:1982638375
Name:BOURQUE, VICTORIA (APRN)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 NYE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1281
Mailing Address - Country:US
Mailing Address - Phone:860-657-3056
Mailing Address - Fax:860-633-3517
Practice Address - Street 1:55 NYE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1281
Practice Address - Country:US
Practice Address - Phone:860-657-3056
Practice Address - Fax:860-633-3517
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT001374363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT890000059Medicare Oscar/Certification
CTS49086Medicare UPIN