Provider Demographics
NPI:1457788390
Name:VAN BOURGONDIEN, DOLORES I (ANP-BC)
Entity type:Individual
Prefix:
First Name:DOLORES
Middle Name:I
Last Name:VAN BOURGONDIEN
Suffix:
Gender:
Credentials:ANP-BC
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 5210
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-5210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4700 S WASHINGTON ST STE G
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-8155
Practice Address - Country:US
Practice Address - Phone:701-205-3000
Practice Address - Fax:701-732-2501
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-10
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9239798363LA2200X
NDR54243363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1695195Medicaid
FL010140700Medicaid