Provider Demographics
NPI:1245993294
Name:BOURN, TAMBLYN LOUISE
Entity type:Individual
Prefix:MS
First Name:TAMBLYN
Middle Name:LOUISE
Last Name:BOURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BOURN
Other - Middle Name:
Other - Last Name:EDUCATOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:11046 168TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11433-3420
Mailing Address - Country:US
Mailing Address - Phone:347-200-0957
Mailing Address - Fax:
Practice Address - Street 1:11046 168TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11433-3420
Practice Address - Country:US
Practice Address - Phone:347-200-0957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty